Intraluminal obliteration of the renal arteries in kidney tumors

A preoperative obliteration of the renal vascular bed was performed in 90 patients by means of Gelfoam emboli. This procedure facilitates the ligation of the renal vein and artery during transabdominal nephrectomy. The decreased vascularity lessens the risk of tumor embolization and reduces the duration of the surgical procedure by half. A simple routine percutaneous method of occlusion is described. Gelfoam emboli are unsuited for permanent obliteration in bleeding tumors.     

Aspects of the nutrition of adult female Glossina morsitans during pregnancy

The hepatic artery was embolized with Gelfoam in 12 dogs to evaluate the effect of embolization on hepatic function. Liver function studies, including SGPT, alkaline phosphatase, BSP test, and bilirubin, were done serially over a 6 week period following the embolization. Eleven of the 12 embolized dogs survived the 6 week experimental period. Hepatic artery embolization caused some liver damage; however, recovery occurred by 6 weeks. These results suggest a possible therapeutic role for hepatic artery embolization in patients with massive hepatic bleeding or hemobilia who are not surgical candidates and who would require hepatic lobectomy or dearterialization to control the bleeding.     

Pelvic fracture with shock-inducing retroperitoneal bleeding and concomitant lower extremity ischemia syndrome: discussion of management exemplified by a case report

BACKGROUND: Initial treatment of severe pelvic fracture consists of appropriate resuscitation and early pelvic reposition and stabilization. Concomitant retroperitoneal arterial bleeding in a hemodynamically unstable patient in combination with lower extremity ischemia make early management decisions very difficult and the mortality rate of this entity of injuries is extremely high. CASE REPORT: We report on a successful treatment of a 36 year old skier, referred in hemorrhagic shock, who had sustained a severely displaced both column fracture of the right acetabulum, an unstable pelvic ring injury on the left and a retroperitoneal bladder rupture. He developed complete ischemia of the right lower extremity. Angiography revealed an obliteration without extravasation of the external iliac artery and allowed treatment of a right superior gluteal artery disruption by embolization. The right lower extremity ischemia was revascularized with a subcutaneous femoro-femoral bypass graft. Delayed internal fixation of the right acetabulum and exploration of the iliac vasculature was done through an ilio-inguinal approach. Simultaneously, the cross-over bypass could be removed. After 18 months, the patient recovered without any ischemic symptoms, but continues with a mixed sciatic nerve lesion. DISCUSSION AND CONCLUSIONS: The combination of severe retroperitoneal arterial bleeding and total ischemia of the lower extremity requires immediate surgical therapy. Direct exploration of the retroperitoneum, however, can be fatal and should be avoided if the iliac vessels are angiographically intact or if a hemorrhage is controllable by an embolization procedure. Extraanatomic temporary revascularization of the lower extremity should be envisaged when a lower leg ischemia due to obliteration or compression of major intrapelvic vessels cannot be directly and immediately treated.     

The metabolic changes associated with trauma and sepsis

BACKGROUND: Intractable epistaxis has been treated with surgical intervention for many years, including ligation of the internal maxillary artery. As an alternative approach, endovascular therapy has gained increased acceptance. The purpose of our study was to evaluate the efficacy and safety of endovascular treatment of untractable epistaxis. METHODS: Embolotherapy was performed in 26 patients. The indication for embolization was persistent epistaxis even after anterior and posterior nasal packing. In all but two patients, who required general anesthesia, the procedure was performed in local anesthesia. Endovascular embolization of the internal maxillary artery was performed by using microcatheters, which were introduced intraarterially. Particulate embolic agents were used in all but one patient, who was treated by means of minicoils. RESULTS: The embolization of the territory of the internal maxillary artery was possible in all cases, the technical success rate was 96%, the clinical success rate was 100%. No complications were encountered. Because of an acute recurrent bleeding in one case, a second embolization was performed. No delayed hemorrhages were noted. CONCLUSIONS: Endovascular embolotherapy seems to be an excellent, safe, and less invasive alternative to surgery in patients with intractable epistaxis.     

Nucleotide substitutions at the -6 position in the promoter region of the factor IX gene result in different severity of hemophilia B Leyden: consequences for genetic counseling

A case of vessel perforation by a guide wire during an interventional neuroradiological procedure is reported. The patient was a 59-year-old woman with a left frontal basal arteriovenous malformation (AVM) fed by the left anterior cerebral artery. Transarterial embolization of the AVM was attempted. During the procedure, vessel perforation by the guide wire occurred at the left A1-A2 junction and resulted in subarachnoid hemorrhage, which stopped spontaneously. The patient developed progressive obstructive hydrocephalus, and surgical treatment was performed. The AVM was totally removed after ventricular drainage, and the arterial perforation site was explored. When clot around the left A1-A2 junction was removed, hemorrhage recurred. This hemorrhage was similar to what has been observed when a small perforating artery was avulsed. The hemorrhage site was coagulated under temporary occlusion of both A1 segments. Surgical intervention was probably not necessary for this type of bleeding if it had stopped spontaneously, because the rebleeding from the small pinhole would be unlikely, and the operation was more hazardous than the usual aneurysmal surgery.     

A case of a ruptured lingual artery aneurysm treated with endovascular surgery

A rare case of a ruptured lingual artery aneurysm treated with endovascular procedure in presented. A 67-year-old woman undergoing treatment in our hospital for right thalamic hemorrhage complained of sudden swelling in the submandibular area and breathlessness. The swelling was so rapid and progressive that her breathing was disturbed. She was intubated as soon as possible. Computed tomography (CT) showed a massive subcutaneous hematoma, extending from the left submandibular area to the neck, which had compressed the trachea to the right. CT with contrast medium showed extravasation of the medium for this lesion. Angiography showed that the aneurysm was located on the periphery of the left ingual artery. Extravasation of contrast medium from the aneurysm was also observed. We considered that direct surgery was difficult to perform safely, so we chose an endovascular procedure to treat this lesion. The lingual artery was successfully embolized using four platinum coils. No rebleeding or other complication occurred after the coil embolization. Disturbance of breathing due to air way obstruction is an important symptom of a ruptured lingual artery aneurysm. Endovascular surgery may be the first choice for treatment of the bleeding origin.     

Role of bronchial artery embolization in the management of hemoptysis

OBJECTIVE: To assess the modern morbidity of hemoptysis and the contribution of therapeutic bronchial artery embolization to its management. METHODS: Medical record review of patients admitted for the treatment of hemoptysis from January 1991 to November 1995 and of patients who had therapeutic bronchial artery embolization from June 1986 to August 1995. Hemoptysis was labeled major or minor. RESULTS: A total of 138 patients were admitted with hemoptysis, 31 with major and 107 with minor hemoptysis. No emergency pulmonary resections were required. Mean follow-up was 13.5 months. Mortality was 29.7% (41/138) but was caused by bronchial bleeding in only 4.3% (6/138). Twenty-six patients underwent therapeutic bronchial artery embolization (mean follow-up [range], 14 months [0.3-69.0 months]). The initial success rate (no further bleeding during the initial admission) was 85% (22/26). The long-term success rate (no further bleeding during follow-up) was 58% (15/26). Only 2 patients with therapeutic bronchial artery embolization died of further hemoptysis. CONCLUSIONS: Hemoptysis signals life-threatening diseases. Therapeutic bronchial artery embolization is a good treatment adjunct to control bronchial bleeding and reduces the need for high-risk emergency lung resections.     

A case of intractable epistaxis

The surgical management of intractable epistaxis by external carotid artery ligation may become complicated if there is a high bifurcation of the common carotid artery. Occlusion of the bleeding vessels by catheter embolization is described in a patient in whom exploration of the neck had failed to locate the external carotid artery.     

Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization

Modern endovascular techniques permit treatment of intracranial aneurysms in many circumstances when surgery is associated with significant morbidity. Occasionally, embolization of aneurysms is unsuccessful or incomplete or followed by complications, in which case surgical management is required. Since 1986, 196 patients have undergone embolization of intracranial aneurysms at the authors' institution and 21 (11%) required subsequent surgical treatment. Attempted embolization failed in five patients (Group A). Ten patients (Group B) had only partial occlusion of the aneurysm or demonstrated recanalization on follow-up studies. Eight of these Group B patients underwent embolization with Guglielmi detachable coils (GDCs), representing 5.7% of the 141 GDC-treated patients in this experience. Surgical treatment in these two groups consisted of clipping (eight cases), surgical parent vessel occlusion (one case), and parent vessel occlusion with extracranial-intracranial bypass (six cases). Fourteen (93%) of the 15 patients in these two groups had an excellent or good outcome with complete aneurysm occlusion. Six patients underwent surgery to treat complications related to the endovascular procedure (Group C). Of these, four patients had neurological improvement compared to their preoperative state, and two died. This series of cases demonstrates that surgical treatment of aneurysms is usually possible with good results following incomplete embolization and emphasizes the need for close and continued neurosurgical involvement in the endovascular management of intracranial aneurysms.     

A case of racemose hemangioma of the right bronchial artery and intercostal to pulmonary arterial anastomosis]

We reported a case of racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis. A 67-year-old woman was admitted because of repeated hemoptysis. Bronchoscopic examination revealed a torous lesion of the right B7 bronchus. Intercostal angiography demonstrated communications between right dilated, meandered intercostal arteries and right pulmonary artery. Bronchial angiography showed dilatation and convolution of the right bronchial artery. Angiographic embolization of the right bronchial artery and the right intercostal artery was underwent. There was no recurrence of hemoptysis one year after the embolization procedure. We think that angiographic embolization is an effective method of treatment of hemoptysis due to racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis.     

Surgical and embolic treatment of cerebral arteriovenous malformations

Twenty-eight cases of cerebral arteriovenous malformations in which the treatment consisted of embolization and/or surgical excision are reviewed. Embolization was considered an adjuvant procedure; carried out to reduce the size of the malformation or eliminate the deep arterial supply to it prior to excision. In sixteen of the cases the combined treatment was carried out with one death and one significant postoperative deficit. In the other twelve cases surgical operation or embolization alone was carried out. The anatomy of the lesion determined the applicability of embolization. Although embolization has a high degree of safety, certain pitfalls must be avoided. Changing patterns in the cerebral circulation following embolization and operation as well as the role of collateral circulation to cerebral arteriovenous malformations are discussed.     

Suppression of heparinization of central venous catheters between cycles of chemotherapy. Results of a phase I study

INTRODUCTION: We investigated the feasibility of the intravascular treatment of iliac aneurysms in patients at high perioperative risk. MATERIAL AND METHODS: January, 1996, to December, 1997, seven iliac aneurysms in 5 patients were treated using endovascular procedures. The patients were 4 men and 1 woman whose mean age was 70 years (range: 61-74 years). Four of 7 aneurysms were in the common iliac artery (2 true aneurysms and 2 anastomotic aneurysms after aortoiliac bypass) and 3 were true internal iliac artery aneurysms. Preoperative CT and arteriography were performed in all cases to define the vascular morphology of the aneurysm, including its exact diameter and length. All procedures were performed in the operating room by a team of vascular radiologists and vascular surgeons, using a portable digital RX system (Philips BV29). The femoral approach was always used, which was percutaneous under local anesthesia in 4 cases and surgical under epidural anesthesia in the other 3 cases, according to the patient's general condition and to common femoral artery morphology. Six endovascular Passager grafts were positioned in the common iliac artery using over-the-wire techniques; platinum coil embolization of the aneurysmatic internal iliac artery had been performed in 2 cases. Coil embolization of the hypogastric artery aneurysm was the only treatment in 1 case. Bilateral aneurysms were treated separately, at intervals of no less than 3 months. RESULTS: Immediate aneurysm exclusion was obtained in all cases, as confirmed at 2-20 months' follow-up in 6 cases. A displaced prosthesis needed reoperation in 1 case. No complications were observed during or early after the procedures, which were always well tolerated by the patients. DISCUSSION: The endovascular treatment of iliac aneurysms is a relatively recent procedure and thus only short- and mid-run results are currently available, which appear satisfactory in 85% of the world's literature cases. Prosthesis displacement and intimal hyperplasia are reported as the main causes of failure. Lacking long-term results, we reserve this method to selected cases. Shorter hospitalization is another advantage. CONCLUSIONS: This little invasive procedure appears suitable for high-risk patients and in the aneurysmatic complications metachronous to surgical bypass.     

Critical evaluation of vascular embolization in patients with Rendu-Osler disease

BACKGROUND: As causal therapy of Rendu-Osler-Weber syndrome is not yet possible, there are many different therapeutical approaches. It seemed expedient to investigate the efficacy of super-selective angiography in treating Rendu-Osler-Weber syndrome after this technique proved effective in other therapeutic settings. This method is known to be efficient in controlling tumor bleeding. PATIENTS: Between March 1993 and September 1995, eight patients with an average age of 57 years were treated by super-selective intraarterial embolization. RESULTS: In all cases epistaxis occurred on both sides. Unilateral embolization was performed in ten cases and bilateral embolization in five cases. In two of three patients with nasal packing the embolization permitted removal of the packing. Nevertheless nosebleeds reoccurred on an average of 3.5 days after therapy. Two of eight patients showed long-term improvement after therapy. They suffered fewer nosebleeds than before. Complications included one patient who suffered from partial hemiparesis after embolization, which lasted 1.5 hours and was completely reversible. Another patient died because of pulmonic bleeding caused by manifestation of the disease in this organ. Often patients complained of facial pain or headache which occasionally lasted for a few weeks. CONCLUSIONS: Endovasal embolization obviously is an alternative to artery ligation in emergency cases whereas the long-term success is currently impaired by formation of new anastomoses. Further development of this technique is necessary.     

Driving cognitive and motor gains with rehabilitation after brain and spinal cord injury

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is rare. Among local pathologic alterations like fibrosis and cirrhosis, arteriovenous shunts lead to hypercirculatory heart failure and require efficient therapy. Present therapeutic strategies consist of percutaneous selective embolization or complete ligation of the hepatic artery. We describe a 53-year-old woman with HHT in whom percutaneous selective embolization of the left hepatic artery failed because of unfavorable anatomy. Instead of ligation a new method of adjustable banding of the hepatic artery was tested. After small-incision laparotomy an expander prosthesis was put on the proper hepatic artery. By filling the prosthesis via the implanted port system the hepatic perfusion could be reduced under control. This method led to effective reduction of the liver perfusion and heart time volume and to successful treatment of heart failure. The method described is an alternative treatment to ligation of the hepatic artery in cases in which percutaneous embolization failed or is not possible.     

Bronchial embolization in the treatment of hemoptysis

The aim of this retrospective study was to evaluate the efficacy of bronchial artery embolization to treat hemoptysis. Eight hundred sixty-five patients were admitted to our hospital with hemoptysis during the study period. Bronchial arteriographs were obtained for 48, who suffered life-threatening hemoptysis refractory to medical treatment. The likely origin of bleeding was identified in 37: embolization was performed with particles measuring 250 to 1000 micra in size (Contour Emboli, Interventional Therapeutic Corporation, South San Francisco, California, USA) in 35 and with hemostatic collagen sponges in 2. The most common causes of hemoptysis were bronchiectasis (40%), pulmonary tuberculosis (33%), pulmonary aspergilloma (8%) and malignant neoplasm (8%), chronic bronchitis (6%); 4% of the cases were idiopathic. Immediate technical success was achieved in 34 patients (92%) as defined by the absence of hemorrhage for at least 24 hours. All embolized patients were followed until the first recurrence of bleeding or until discharge. Recurrence of hemoptysis (in the first month) was early in 5 patients (13.5%) and late (2 to 96 months) in 9 (24%). The severity of the initial and later episodes of hemoptysis was similar in all early recurrences and most late recurrences. A second embolization was performed six times, and medical and/or surgical treatment was given in all other cases. No significant complications attributable to the technique were observed. The results show that bronchial embolization is valid for the immediate control of life-threatening hemoptysis and has a low rate of severe complication; recurrence is relatively common.     

Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application

Surgical allograft nephrectomy has been the conventional therapy for removing failed kidney allografts when clinical manifestations of graft intolerance appear. However, removal of a transplanted kidney is an extensive surgical procedure. On the other hand, transcatheter vascular embolization (TVE) has proven useful in ablating organs and could be applied to renal transplant ablation. The aim of this study was to present the results of TVE for the treatment of graft intolerance syndrome (GIS) in failed allograft kidneys. Transcatheter vascular embolization was performed in 14 allograft recipients (33 +/- 13 years of age; 10 men and four women) affected by GIS after irreversible kidney allograft failure. Graft intolerance syndrome was diagnosed by fever (93%), hematuria (50%), graft pain (36%), flu-like symptoms (29%), and increased graft size (29%). Absolute ethanol (0.1 mL/kg body weight) was injected in the allograft artery, and in seven patients a stainless steel coil was left in the renal artery following ethanol injection. All patients showed clinical disappearance of the GIS. No major complication occurred, although a postembolization syndrome of pain, fever, hematuria, numbness, and paresthesia of the affected area appeared in 11 of the 14 patients. After 2 to 56 months of follow-up no late complications occurred, with the exception of a graft abscess formation in one patient after 6 months of embolization. Subsequent transplantectomy was uneventful. In conclusion, TVE is a safe and effective method for kidney graft ablation, and it may become an alternative treatment for GIS following irreversible rejection.     

The treatment of hemoptysis by embolization of the systemic arteries (author's transl)

The authors present their still limited experience of embolization of systemic arteries as the treatment of hemoptysis. Their cases illustrate the indications, contra-indications, causes of failure and effectiveness of this therapeutic method in pneumology. They had to refuse who patients: in the first, the pathological bronchial artery arose from a common trunk with the intercostal which gave rise to an anterior spinal artery. The second patient showed signs of medullary involvement on injection of a pathological right intercostal artery, which in their opinion is also a contra-indication of embolization, although no anterior spinal artery was demonstrated on the arteriogrammes. Six patients were treated by embolization. In the case of one patient, treatment was a failure owing to incomplete embolization. A main esophageal pedicle supplied a high flow bronchial artery anastomosis. These important collateral esophageal vessels compromize the effectiveness of bronchial embolization.     

Percutaneous control of post-traumatic hepatic hemorrhage by gelfoam embolization

A case is reported in which a male laborer sustained severe hepatic lacerations after a tree fell across his abdomen. Despite intensive resuscitation and a laparotomy, bleeding continued from the liver and a second laparotomy was performed. When this also failed to control the hemorrhage a selective hepatic angiogram showed a false aneurysm in the right lobe of the liver with surrounding hematoma. This was successfully embolized with Gelfoam emboli. Bleeding ceased immediately with an uneventful recovery. The role of embolization in the management of hepatic trauma is discussed, especially in relation to surgical hepatic artery ligation.     

Reflections on the management of cerebral arteriovenous malformations

BACKGROUND: The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience. METHODS: A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates. RESULTS: The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure. CONCLUSIONS: In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered "good risk" malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered "poor risk" malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.     

Esophageal manometric studies in children with achalasia before and after operative treatment

A 68-year-old woman was found crouching in the kitchen with severe upper abdominal pain. She entered a state of shock at our emergency clinic. Abdominal computed tomography (CT) scan demonstrated a 3 cm cystic mass dorsal to the pancreas tail accompanied with a hematoma. On angiography, a bleeding from the left middle adrenal artery was identified and embolized for hemostasis. An operation was performed 3.5 months after embolization. Preoperative evaluation showed the tumor to be endocrinologically inactive. Metoclopramide stimulation test was negative, too. Left adrenalectomy was performed uneventfully without intraoperative increase in blood pressure. However, histopathological diagnosis was pheochromocytoma. Transarterial embolization is an effective treatment for adrenal bleeding. In our case, however, embolization might have caused the tumor to be falsely "endocrinologically inactive".