To evaluate the clinical efficacy and safety of a transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for the treatment of arterial esophageal bleeding.
Materials and Methods
Between August 2000 and April 2008, five patients diagnosed with arterial esophageal bleeding by conventional angiography, CT-angiography or endoscopy, underwent a TAE with NBCA. We mixed NBCA with iodized oil at ratios of 1:1 to 1:4 to supply radiopacity and achieve a proper polymerization time. After embolization, we evaluated the angiographic and clinical success, recurrent bleeding, and procedure-related complications.
The bleeding esophageal artery directly originated from the aorta in four patients and from the left inferior phrenic artery in one patient. Although four patients had an underlying coagulopathy at the time of the TAE, angiographic and clinical success was achieved in all five patients. In addition, no procedure-related complications such as esophageal infarction were observed during this study.
NBCA can be an effective and feasible embolic agent in patients with active arterial esophageal bleeding, even with pre-existing coagulopathy.
Esophageal artery; Hemorrhaging; Angiography; Therapeutic embolization
We present two cases of acquired uterine arterial venous malformation (AVM) which was diagnosed because of massive genital bleeding successfully treated with transcatheter arterial embolization (TAE), using N-butyl-2-cyanoacrylate (NBCA) under balloon occlusion. Balloon occlusion at the uterine artery was performed in both patients for diffuse distribution of NBCA in multiple feeding branches, as well as to the pseudoaneurysm, and for the prevention of NBCA reflux. In one of our patients, balloon occlusion of the draining vein was simultaneously performed to prevent NBCA migration through accompanying high-flow arteriovenous fistula (AVF). Doppler ultrasound at 6 months of both patients documented persistent complete occlusion of AVM. Complete and safe obliteration of acquired uterine AVM was accomplished using NBCA as embolic agent, under balloon occlusion at the communicating vessels of acquired uterine AVM.
Acquired arteriovenous malformation; embolization; obstetrics
The liquid embolic agent n-butyl cyanoacrylate (NBCA) is a tissue adhesive used as an immediate and permanent embolic agent when mixed with oil-based contrast medium. In this study, the preservation of fertility with TAE using NBCA for massive haemorrhage during pregnancy or the peripartum period and the utility of this therapy were investigated.
Cases from January 2005 to October 2010 in which TAE was performed for massive haemorrhage in pregnant women, particularly during the peripartum period, were investigated.
TAE was performed in 27 pregnant women. The embolic agent used was GS only in five cases, NBCA only in 19 cases, and additional embolization with NBCA when the effect with GS was insufficient in three cases, one each of abruptio placentae, cervical pregnancy, and uterine atony.A comparison of mean blood loss when each embolic agent was used for haemostasis showed a significant difference between cases in which GS only was used and cases in which NBCA only was used. In a comparison of mean transfusion volume, a significant difference was seen between cases in which both GS and NBCA were used and cases in which NBCA only was used. In a postoperative follow-up survey, menses resumed in eight patients, including four patients who later became pregnant and three who delivered.
TAE with NBCA, which has an embolic effect unrelated to clotting dysfunction for massive haemorrhage during the peripartum period, is a minimally invasive and very effective treatment method for patients with severe DIC.
To evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-Butyl Cyanoacrylate (NBCA) for nonvariceal upper gastrointestinal bleeding.
Materials and Methods
Between March 1999 and December 2002, TAE for nonvariceal upper gastrointestinal bleeding was performed in 93 patients. The endoscopic approach had failed or was discarded as an approach for control of bleeding in all study patients. Among the 93 patients NBCA was used as the primary embolic material for TAE in 32 patients (28 men, four women; mean age, 59.1 years). The indications for choosing NBCA as the embolic material were: inability to advance the microcatheter to the bleeding site and effective wedging of the microcatheter into the bleeding artery. TAE was performed using 1:1-1:3 mixtures of NBCA and iodized oil. The angiographic and clinical success rate, recurrent bleeding rate, procedure related complications and clinical outcomes were evaluated.
The angiographic and clinical success rates were 100% and 91% (29/32), respectively. There were no serious ischemic complications. Recurrent bleeding occurred in three patients (9%) and they were managed with emergency surgery (n = 1) and with a successful second TAE (n = 2). Eighteen patients (56%) had a coagulopathy at the time of TAE and the clinical success rate in this group of patients was 83% (15/18).
TAE with NBCA is a highly effective and safe treatment modality for nonvariceal upper gastrointestinal bleeding, especially when it is not possible to advance the microcatheter to the bleeding site and when the patient has a coagulopathy.
Gastrointestinal tract, hemorrhage; Angiography, therapeutic embolization
Penetrating venous injuries via Zone III of the neck extended over jugular bulb are rare. The optimal strategies for these venous injuries are currently unknown because many of the vital structures in this region are poorly accessible to the surgeon and therefore it is difficult to control bleeding. A 76-year-old man got drunk and fell down onto a paper door. The wooden framework of the paper door was broken and got stuck deep in the right side of his neck. Enhanced computed tomography showed the wood stick had penetrated through the right jugular foramen and injured the jugular bulb. We successfully performed right sigmoid and jugular vein occlusion via an endovascular approach using Guglielmi detachable coils at first and then to draw out the wood stick in order to avoid venous bleeding. To our best knowledge, these venous injuries have reported in only four cases. Only one case was performed by endovascular approach using n-butyl cyanoacrylate (NBCA). Coil embolization is much better than NBCA in the light of reducing complications due to adhesion to the inserted wood stick and embolization of unintended vessels. Venous occlusion using coil embolization is the best way to treat a penetrating jugular bulb injury via zone III because of reducing the hemorrhage and air embolism.
coil embolization, endovascular therapy, jugular vein injury, neck trauma, zone III
AIM: To compare the efficacy and safety of bronchial artery embolization (BAE) with n-butyl cyanoacrylate (NBCA) and gelatin sponge particles (GSPs).
METHODS: Six healthy female swine were divided into two groups to be treated with BAE using NBCA-lipiodol (NBCA-Lp) and using GSPs. The occlusive durability, the presence of embolic materials, the response of the vessel wall, and damage to the bronchial wall and pulmonary parenchyma were compared.
RESULTS: No animals experienced any major complication. Two days later, no recanalization of the bronchial artery was observed in the NBCA-Lp group, while partial recanalization was seen in the GSP group. Embolic materials were not found in the pulmonary artery or pulmonary vein. NBCA-Lp was present as a bubble-like space in bronchial branch arteries of 127-1240 μm, and GSPs as reticular amorphous substance of 107-853 μm. These arteries were in the adventitia outside the bronchial cartilage but not in the fine vessels inside the bronchial cartilage. No damage to the bronchial wall and pulmonary parenchyma was found in either group. Red cell thrombus, stripping of endothelial cells, and infiltration of inflammatory cells was observed in vessels embolized with NBCA-Lp or GSP.
CONCLUSION: NBCA embolization is more potent than GSP with regard to bronchial artery occlusion, and both materials were present in bronchial branch arteries ≥ 100 μm diameter.
Bronchial artery embolization; Embolic materials; N-butyl cyanoacrylate; Gelatin sponge; Lipiodol
BACKGROUND--A number of reports of radiologically guided percutaneous biopsy of mediastinal masses have been described but techniques have varied, particularly the type of needle used. In this study mediastinal biopsies with fine aspiration needles and cutting needles have been compared, sometimes in the same patient. The results are reviewed with particular emphasis on the choice of biopsy needle and its influence on pathological diagnosis. METHODS--A retrospective review was undertaken of radiologically guided mediastinal biopsies performed between 1981 and 1991. RESULTS--Sixty fine needle aspiration biopsies (FNA) and 34 Tru-Cut biopsies of mediastinal masses were performed in 75 patients with fluoroscopic or computed tomographic guidance. Overall sensitivity and specificity in terms of diagnosis of malignant disease were 90% and 100% respectively for FNA biopsies, and 96% and 100% for Tru-Cut biopsies. Diagnostic accuracy in terms of precise diagnosis of the malignant or benign nature of a mass and its origin was 77% for FNA biopsies and 94% for Tru-Cut biopsies. For FNA biopsies sensitivity and accuracy were higher for carcinomatous lesions (96% and 88%) than for noncarcinomatous lesions (81% and 69%). The only significant complication encountered was a pneumothorax following a biopsy which required intercostal drainage. CONCLUSIONS--Radiologically guided percutaneous needle biopsy is a safe procedure which provides useful diagnostic information in the majority of cases. Fine needle aspiration techniques usually suffice for carcinomatous lesions but a cutting needle biopsy should be performed whenever possible when lymphoma, thymoma, or neural masses are suspected to obtain larger specimens for more accurate histological diagnosis.
We report on cases of life-threatening maxillomandibular arteriovenous malformations (AVM) whereby patients had successful endovascular treatment with good outcomes. Out of a total 93 facial AVMs treated endovascularly between 1991 and 2009, five patients (5.4%) had maxillomandibular AVMs. All presented with uncontrolled dental bleeding. Endovascular procedure was the primary treatment of choice in all cases, either transfemoral approach with arterial feeder embolization or transosseous puncture, depending on the accessible route in each patient. NBCA (glue) was the only embolic agent used. Tooth extraction and dental care were performed after bleeding was controlled.
All five patients (8-18 years) with a mean age of 12.4 years presented with massive dental bleeding following loosening of teeth, dental extraction and/or cheek trauma. The plain films and CT scans of four patients with AVMs of mandibles and one of maxilla, revealed expansile osteolytic lesions. The mean follow-up period was 6.6 years (ranging between one and 19 years). Three cases developed recurrent bleeding between two weeks to three months after first embolization, resulting from residual AVM and infection. Late complications occurred in two patients from chronic localized infection and osteonecrosis, which were successfully eradicated with antibiotic therapy and bony curettage. Complications occurring in two patients which included soft tissue infection, osteomyelitis and osteonecrosis were successfully treated with antibiotics, curettage and bone resection. No patient had a recurrence of bleeding after the disease had cured
Initial glue embolization is recommended as the effective treatment of dental AVMs for emergent bleeding control, with the aim to complete eradicate the intraosseous venous pouches either by means of transarterial superselection or direct transosseous puncture. Patient care by a multidisciplinary team approach is important for sustained treatment results.
maxillomandibular, AVM, embolization
Patient: Male, 19
Final Diagnosis: Hyperleukocytosis • thrombocytosis
Symptoms: Hyperleukocytosis • retroperitoneal hemorrhage • thrombocytosis
Clinical Procedure: Bone marrow trephine biopsy
Specialty: Hematology • Radiology
Bone marrow (BM) trephine biopsy is generally a safe procedure, but adverse events such as retroperitoneal hemorrhage (RPH) may occur. We report 3 cases of this complication.
A 19-year-old male with thrombocytopenia and coagulopathy underwent BM trephine biopsy to confirm relapse of acute lymphoblastic leukemia. Two hours later, he developed severe hypotension and a CT scan revealed a massive RPH, and was treated conservatively. The RPH recurred 2 weeks after chemotherapy and was successfully treated with gel foam embolization. A 55-year-old male with coagulopathy underwent BM trephine biopsy for hyperleukocytosis and thrombocytosis. He developed a large RPH preceded by left lumbar dermatome sensory neuropathy. He was treated conservatively. A 56-year-old overweight woman on aspirin underwent BM trephine biopsy for polycythemia. Twelve hours later she developed severe abdominal pain with hypotension. A CT scan showed a massive RPH and secondary hemothorax. She was treated conservatively and the RPH resolved after several months.
We and others showed that myeloproliferative neoplasm, quantitative or qualitative platelet abnormalities, aspirin, coagulopathy, and obesity are associated with development of RPH following BM trephine biopsy. Early diagnosis and intervention are crucial. Correction of coagulopathy and cessation of anti-platelet treatment prior to biopsy can prevent this serious complication.
bone marrow trephine biopsy; retroperitoneal hemorrhage; Retroperitoneal hematoma
Varicoceles are abnormally dilated veins within the pampiniform plexus. They are caused by reflux of blood in the internal spermatic vein. The incidence of varicoceles is approximately 10–15% of the adolescent male population. The etiology of varicoceles is probably multifactorial. The diagnosis is based on Doppler US. Treatment could be endovascular or surgical.
The aim of the study was to describe and evaluate a novel method of endovascular embolization of varicoceles using n-butyl cyanoacrylate (NBCA) glue.
17 patients were subjected to endovascular treatment of varicoceles using NBCA. A 2.8 Fr microcatheter and a 1:1 mixture of NBCA and lipiodol were used for embolization of the spermatic vein.
All 17 procedures were successful. There were no complications.
Embolization of varicoceles using NBCA glue is efficient and safe for all patients. The method should be considered as a method of choice in all patients. Phlebography and Valsalva maneuver are crucial for technical success and avoidance of complications.
Endovascular treatment of varicoceles using NBCA glue is very effective and safe.
varicoceles; embolization; n-butyl cyanoacrylate
Hepatic artery pseudoaneurysms (HAP) are rare events, particularly after liver biopsy, but can be associated with serious complications. Therefore a high suspicion is necessary for timely diagnosis and appropriate treatment. We report on a case of HAP that potentially formed after a liver biopsy in a patient with sarcoidosis. The HAP in our case was virtually undetectable initially by angiography but resulted in several complications including recurrent gastrointestinal bleeding, hemorrhagic cholecystitis and finally hepatic infarction with abscess formation until it became detectable at a size of 5-mm. The patient remains asymptomatic over a year after endovascular embolization of the HAP. In this report, we demonstrate that a small HAP can avoid detection by angiography at an early stage while being symptomatic for a prolonged course. A high clinical suspicion with a close clinical/radiological follow-up is needed in symptomatic patients with history of liver biopsy despite initial negative work up. Once diagnosed, HAP can be safely and effectively treated by endovascular embolization.
Gastrointestinal bleed; Abnormal liver enzymes; Hepatic artery pseudoaneurysms; Liver biopsy; Angiography
Percutaneous endoscopic gastrostomy (PEG) is often performed for alimentation and to prevent weight loss in patients with feeding problems due to central neurologic diseases such as cerebral infarction or intracranial hemorrhage. Although infection at the skin site after PEG placement is a typical late complication of PEG, a ruptured infectious pseudoaneurysm caused massive bleeding adjacent to the tract is rare. Prompt treatment is required to avoid the hemorrhage shock, however surgical ligation is difficult to obtain the arrest of bleeding in damaged skin due to the infection.
A 70-year-old male was bedridden due a cerebral infarction suffered 1 year previously. APEG was placed because of feeding problems, and a push-type, 20-Fr gastrostomy tube was inserted through the anterior abdominal wall. On day 16 after PEG placement, the patient had massive bleeding from the PEG site due to the rupture of infectious pseudoaneurysm and developed a decreased level of consciousness and hypotension. Treatment by percutaneous direct injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol was performed and achieved good hemostasis is obtained.
A rare case of an infectious pseudoaneurysm that developed in the abdominal wall and caused massive bleeding at a PEG placement site was described. Percutaneous injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol under ultrasound guidance is an effective treatment in this case.
n-butyl-cyanoacrylate-lipiodol; Infectious pseudoaneurysm; Abdominal wall; Percutaneous endoscopic gastrostomy
The current study retrospectively evaluated whether the percutaneous N-butyl cyanoacrylate (NBCA) seal-off technique is an effective treatment for controlling the angioplasty-related ruptures, which are irresponsive to prolonged balloon tamponade, during interventions for failed or failing hemodialysis vascular accesses.
Materials and Methods
We reviewed 1588 interventions performed during a 2-year period for dysfunction and/or failed hemodialysis vascular access sites in 1569 patients. For the angioplasty-related ruptures, which could not be controlled with repeated prolonged balloon tamponade, the rupture sites were sealed off with an injection of a glue mixture (NBCA and lipiodol), via a needle/needle sheath to the rupture site, under a sonographic guidance. Technical success rate, complications and clinical success rate were reported. The post-seal-off primary and secondary functional patency rates were calculated by a survival analysis with the Kaplan-Meier method.
Twenty ruptures irresponsive to prolonged balloon tamponade occurred in 1588 interventions (1.3%). Two technical failures were noted; one was salvaged with a bailout stent-graft insertion and the other was lost after access embolization. Eighteen accesses (90.0%) were salvaged with the seal-off technique; of them, 16 ruptures were completely sealed off, and two lesions were controlled as acute pseudoaneurysms. Acute pseudoaneurysms were corrected with stentgraft insertion in one patient, and access ligation in the other. The most significant complication during the follow-up was delayed pseudoaneurysm, which occurred in 43.8% (7 of 16) of the completely sealed off accesses. Delayed pseudoaneurysms were treated with surgical revision (n = 2), access ligation (n = 2) and observation (n = 3). During the follow-up, despite the presence of pseudoaneurysms (acute = 1, delayed = 7), a high clinical success rate of 94.4% (17 of 18) was achieved, and they were utilized for hemodialysis at the mean of 411.0 days. The post-seal-off primary patency vs. secondary patency at 90, 180 and 360 days were 66.7 ± 11.1% vs. 94.4 ± 5.4%; 33.3 ± 11.1% vs. 83.3 ± 8.8%; and 13.3 ± 8.5% vs. 63.3 ± 12.1%, respectively.
Our results suggest that the NBCA seal-off technique is effective for immediate control of a venous rupture irresponsive to prolonged balloon tamponade, during interventions for hemodialysis accesses. Both high technical and clinical success rates can be achieved. However, the treatment is not durable, and about 40% of the completely sealed off accesses are associated with developed delayed pseudoaneurysms in a 2-month of follow-up. Further repair of the vascular tear site, with surgery or stent-graft insertion, is often necessary.
Angioplasty, balloon; Arteriovenous shunt, surgical; Rupture; Cyanoacrylates; Aneurysm, false
Fine-needle aspiration is the procedure of choice for evaluating thyroid nodules. Core-needle biopsy (CNB) is not included in the American Thyroid Association recommendations for evaluating such nodules. CNB complications are classically bleeding and hematomas. To our knowledge, no case of arteriovenous fistula (AVF) secondary to a CNB has been reported, nor has any case of tinnitus secondary to a post-CNB AVF.
To make the clinician aware of possible vascular complications caused by CNB and the possibility of difficult pathology reading caused by previous CNB.
A 44-year-old female is described who was referred to our tertiary care center for left-sided pulsatile tinnitus. She did report having had a CNB right before the tinnitus appeared. Conventional angiography demonstrated a focal AVF originating from the left vertebral artery, with reflux to the left vertebral venous plexus. A 6-mm stent was placed over the site of the fistula via an endovascular approach, which solved both the radiological and clinical documented problems. Moreover, CNB greatly complicated pathology reading once total thyroidectomy was later performed. The suspected area of invasion was an artifact due to the previous biopsies.
Although many authors recommend a CNB as an alternative modality in cases of inconclusive cytology with fine-needle aspiration, it is not in the American Thyroid Association recommendations. In cases of iatrogenic AVFs caused by a CNB, angiography is recommended both as a diagnostic and therapeutic modality. Stenting the fistula with an endoprosthesis can correct the problem immediately.
Arteriovenous fistula; Thyroid; Core needle biopsy; Tinnitus; Stent
Neurofibromatosis is generally a benign disease, but has the potential for rare and fatal complications, such as spontaneous hemothorax. We report a case of massive hemothorax due to neurofibroma in a 49-year-old woman with neurofibromatosis type 1. The configuration of the radiological opacity and frank blood withdrawn on thoracentesis should suggest the diagnosis of hemothorax in a patient with neurofibromatosis. Surgical treatment for hemothorax is limited by arterial fragility and the prognosis is relatively poor. Any evidence of aneurysmal disease in the thoracic vessels should be aggressively managed percutaneously by coil embolization to prevent future rupture.
Neurofibroma; neurofibromatosis type I; spontaneous hemothorax
We report that a case of primary abdominal compartment syndrome (ACS), caused by blunt liver injury under the oral anticoagulation therapy, was successfully treated. Transcatheter arterial embolization (TAE) was initially selected, and the bleeding point of hepatic artery was embolized with N-Butyl Cyanoacylate (NBCA). Secondary, percutaneous catheter drainage (PCD) was performed for massive hemoperitoneum. There are some reports of ACS treated with TAE. However, combination treatment of TAE with NBCA and PCD for ACS has not been reported. Even low invasive interventional procedures may improve primary ACS if the patient has hemorrhagic diathesis or coagulopathy discouraging surgeon from laparotomy.
Abdominal compartment syndrome; Transcatheter arterial embolization; N-butyl cyanoacylate
Embolization using n-butyl-cyanoacrylate (NBCA) for arteriovenous malformation (AVM) is now a daily practice over the world, but there exists no objective data that can be a basis for discussion or decision-making on the best concentration and injection rate of NBCA mixture. The purpose of this study was to obtain objective data on control and behavior of NBCA mixture with an in vitro simulation system of NBCA embolization for AVM.
A nidus model made of a one-ml syringe filled with small beads was connected to a pulsatile flow circuit. A microcatheter was introduced just before the nidus model. Endoluminal pressures proximal and distal to the nidus and flow volume through the nidus were measured. Digital subtraction angiography (DSA) was performed to calculate transit time of the contrast medium (CM) through the nidus. NBCA was injected at various rates with an autoinjector and transit time of NBCA through the nidus was calculated.
27 trials were completed. Transit time of CM through the nidus model is well correlated to flow volume per unit of time through the nidus model. Shorter the transit time, larger was the flow volume per unit of time. The correlation was statistically significant (P < .0001). Though statistical significance was not attained, transit time of NBCA mixture at 50% concentration had a tendency to be correlated to flow volume per unit of time through the nidus, and slower injection of the NBCA mixture led to slower filling of the nidus model.
Though this simulation system was artificial and the results should be interpreted carefully, it was shown with this system that transit time of CM through the nidus could be a good index for flow volume per unit of time through the nidus. Also suggested was a possibility to utilize this in vitro system for research and training on NBCA embolization of AVM.
AVM, embolization, NBCA
Bleeding from Gastric Varices (GV) is not only life threatening, but also leads to many hospitalizations, contributes to morbidity and is resource intensive. GV are difficult to diagnose and their treatment can be challenging due to their location and complex structure. To assess the safety and efficacy of endoscopic gastric fundal variceal gluing using periodic endoscopic injections of N-butyl-2-cyanoacylate (NBCA) and to assess the utility of endoscopic ultrasound (EUS) in assessing for the eradication of GV post-NBCA treatment.
Materials and Methods:
Analysis of prospectively collected data of a cohort of patients with GV who underwent periodic endoscopic variceal gluing from 2005 to 2011. Outcomes included success of GV obliteration, incidence of rebleeding, complications from the procedure, and analysis of factors that might predict GV rebleeding. The success of GV eradication was assessed by both EUS and direct endoscopy.
The cohort consisted of 29 consecutive patients that had undergone NBCA injection for GV. The mean age was 60.8 years standard deviations (SD 13.3, range 20-81). The average follow-up was 28 months (SD 19.61, range 1-64) and the most common cause for GV was alcoholic liver cirrhosis (34.48%). A total of 91 sessions of NBCA injections were carried out for 29 patients (average of 3.14 sessions/patient, SD 1.79, range 1-8) with a total of 124 injections applied (average of 4.28 injections/patient, SD 3.09, range 1-13). 24 patients were treated for previously documented GV bleeding while five were treated for primary prevention. Overall, 79% of patients were free of rebleeding once three sessions of histoacryl® injection were completed. None of the patients treated for primary prevention developed bleeding during follow-up. 11 of the 24 patients (46%) with previous bleeding however had rebleeding. 4/11 (36%) patients had GV rebleeding while awaiting scheduled additional NBCA sessions. 19/29 (60%) patients had complete eradication of GV, 11/19 (58%) documented by endoscopic assessment alone, 4/19 (21%) by EUS alone and 4/19 (21%) by both techniques. Two of the 11 (18%) patients that had rebleeding had recurrence of GV bleeding after documented eradication by EUS compared to 5/11 (45%) patients documented eradication by endoscopic assessment and 2/11 (18%) patients that had rebleeding after documented eradication by both modalities. Twenty five patients in total had documented residual GV by EUS (14, 56%), direct endoscopic assessment (18, 72%) or both modalities (9, 36%), two of which developed recurrent bleeding (13%). No immediate or long-term complications of NBCA injection occurred, nor any related endoscopic complications were reported in any of these cases during the time of follow-up.
NBCA injection of GV is a safe and successful therapeutic intervention. A minimum of three endoscopic sessions is required to significantly decrease the risk of bleeding/rebleeding. In this small sample of patients, neither EUS nor direct endoscopic assessment was reliable in predicting the recurrence of GV bleeding.
Cyanoacrylate injection; gastric varices; rebleeding
We present a case of a patient with rapid deterioration of esophageal varices caused by portal hypertension accompanied by a large arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma. We used n-butyl cyanoacrylate (NBCA) as an embolic material to achieve pinpoint embolization of the shunt, because the microcatheter tip was 2 cm away from the shunt site. Under hepatic arterial flow control using a balloon catheter, the arterioportal shunt was successfully embolized with NBCA, which caused an improvement in the esophageal varices.
Arterioportal shunt; Balloon catheter; Blood flow control; Embolization; N-butyl cyanoacrylate
BACKGROUND: Malignancies located in the upper middle mediastinum usually do not have a sufficiently large acoustic window to permit a conventional ultrasound guided parasternal biopsy. This study was concerned with an alternative approach whereby ultrasound is applied through the supraclavicular paratracheal window to allow percutaneous biopsy of middle mediastinal malignancies. METHODS: Fifteen patients who had upper mediastinal malignancies not in contact with the chest wall underwent real time and Doppler ultrasonographic studies by the supraclavicular approach. None of these tumours could be reached by conventional ultrasound guided parasternal biopsy. The ultrasound was scanned downwards through the supraclavicular fossa, along the acoustic window of the paratracheal soft tissue space. Percutaneous aspiration biopsy was performed with a 22 gauge needle under ultrasound guidance. If fine needle aspiration could not obtain an adequate tissue smear an 18 gauge Trucut biopsy was performed to obtain a histological diagnosis. RESULTS: Twelve of 15 mediastinal malignancies were detected by ultrasound through the supraclavicular approach. These 12 patients underwent percutaneous needle aspiration biopsy under ultrasound guidance. Four of the patients also had a Trucut biopsy because the needle aspirates from the tumours were inadequate. The needle had to pass through the jugular veins in four patients who received fine needle aspiration but in none of the patients who required a Trucut biopsy. Definite histological diagnoses were obtained in all 12 of these patients. Ten of the tumours were malignant and two benign. None of the patients developed any complication. CONCLUSIONS: Ultrasound and ultrasound guided biopsy through the supraclavicular paratracheal window provides a new approach for malignancy located in the upper middle mediastinum, which cannot be reached by conventional ultrasound guided parasternal biopsy. The diagnostic yield of this technique is high and the procedure is relatively safe.
The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding.
Materials and Methods
We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients.
Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; ± 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization.
Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.
Bleeding; Embolization; Pancreaticoduodenal artery; Sphincterotomy
To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.
Materials and Methods
We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.
The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.
Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.
Uterine artery embolization; Digital subtraction angiography; Uterine myomectomy; Uterine myoma
Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues. With disease progression, patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss. Among them, a pseudoaneurysm, mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas, is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs. At present, no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation. The role of arterial embolization, the timing of surgical intervention and even surgical procedures are still controversial. In this review, we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleeders and to evaluate the associated complications such as pseudocyst formation, followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition. With advances and improvements in endoscopic devices and techniques, therapeutic endoscopy for pancreatic pseudocysts is technically feasible, safe and effective. Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition, for those in whom arterial embolization of the bleeding pseudoaneurysm fails, and when endoscopic management of the pseudocyst is unsuccessful. If a bleeding pseudoaneurysm is located over the tail of the pancreas, resection is a preferential procedure, whereas if the lesion is situated over the head or body of the pancreas, relatively conservative surgical procedures are recommended.
Chronic pancreatitis; Pseudocyst; Pseudoaneurysm bleeding; Arterial embolization; Endoscopy; Surgery
We present a case of a ruptured vertebral artery dissecting aneurysm that mimicked a presumed vascular anomaly by CTA (Computerized Tomographic Angiography). A parenchymal arteriovenous malformation (AVM) or a dural arteriovenous fistula (DAVF) at the craniocervical junction can present with a subarachnoid hemorrhage and cannot be differentiated from a vertebral artery dissection by non invasive imaging. Catheter based cerebral angiography revealed a dissecting pseudoaneurysm of a diminutive right vertebral artery terminating in the posterior inferior cerebellar artery (PICA) that to our knowledge has not been previously reported. NBCA (N-Butyl Cyanoacrylate) embolization of the pseudoaneurysm lumen and sacrifice of the parent vessel resulted in cerebellar infarction, requiring an emergent decompressive craniectomy. The patient recovered to a functional neurologic status.
Subarachnoid hemorrhage; Vertebral artery dissection; Arteriovenous Malformation; Cyanoacrylate embolization
The use of bilateral internal iliac artery embolization to control hemorrhage associated with pelvic fractures is a life saving intervention. Gluteal necrosis is a rare but potentially fatal complication of this procedure. Following debridement, reconstruction can present a considerable challenge due to the compromised vascularity of local tissue.
PRESENTATION OF CASE
A 17 year old girl suffered an open book pelvic fracture following a road traffic accident. In order to stop profuse bleeding, bilateral internal iliac artery embolization was performed. This procedure was complicated by the development of right sided gluteal necrosis. Following extensive debridement, a transposition flap based on the lumbar artery perforators was performed to cover the soft tissue defect.
Gluteal necrosis occurs in approximately 3% of cases following internal iliac artery embolization. Following complete excision of the devitalised tissue reconstructive surgery is necessary. Local flaps are suboptimal options when the integument supplied by branches of the internal iliac arteries has been compromised following embolization. Furthermore, the use of a free flap is restricted by the lack of a readily accessible undamaged recipient vessel. In the present case a transposition flap based on the lumbar artery perforators facilitated robust reconstruction of the buttock region.
To avoid sepsis, it is imperative that gluteal necrosis following internal iliac artery embolization is recognized and promptly debrided. A transposition flap based on the lumbar artery perforators is a good option for subsequent soft tissue coverage, which avoids use of tissue supplied by the branches of the internal iliac arteries.
Gluteal necrosis; Lumbar artery; Transposition flap; Embolization; Internal iliac artery