Azzam Anwar Khankan

Embolization of High Flow Arteriovenous Malformations: Experience with Use of Superabsorbent Polymer Microspheres

PURPOSE To determine efficacy, safety, and requirements for adjunctive embolization or surgery in the treatment of symptomatic arteriovenous malformations (AVMs) with superabsorbent polymer microsphere (SAP-MS) particles. MATERIALS AND METHODS SAP-MS particles (sodium acrylate and vinyl alcohol copolymer) are nonbiodegradable spheres with a precisely calibrated diameter. SAP-MS particles swell by absorbing fluids and become soft and deformable. Twenty-five patients (16 men, nine women; mean age, 32 y; range 12-66 y) with symptomatic facial (n = 5), upper- (n = 8) and lower- (n = 12) extremity AVMs were treated primarily (n = 23) or preoperatively (n = 2) by transarterial embolization (TAE) treatment with use of SAP-MS particles. Direct puncture embolization (DPE; n = 4) and/or surgical intervention (n = 5; ie, skin graft, resection, or amputation) were required. Surgical specimens from the resected (n = 2) and the amputated (n = 2) patients were evaluated histologically. Follow-up study, including clinical findings and imaging studies, was performed at intervals ranging from 3 months to 1 year. Clinical outcome was evaluated retrospectively, depending on the subjective improvement of symptoms and signs, according to the medical records. RESULTS Seventy-two TAEs (range, 1-11; mean, 2.8) and 12 DPEs (range, 1-3; mean, 2.4) were performed during the mean follow-up period of 38 months (range, 7-110 mo). Twenty patients (80%) experienced symptom improvement by embolotherapy alone (n = 17) or in combination with surgery (n = 3). One lip and two finger AVMs were totally removed by surgical excision or amputation after TAE treatment. In diffuse upper- (n = 1) and lower- (n = 1) extremity AVMs, the symptoms were uncontrolled. No nerve injury or skin necrosis was observed after TAE treatment with SAP-MS particles. Mucosal necrosis was induced by DPE with ethanol in one patient. Histologically, SAP-MS particles penetrated intralesional vessels and conformed to the vessel lumen, resulting in tight vessel occlusion. Minimal perivascular reaction was observed. CONCLUSION SAP-MS particles were used safely in TAE treatment of AVM. TAE treatment with use of SAP-MS particles was suitable for certain symptomatic AVMs, but diffuse AVMs remain a challenge and a combination of alternative methods will be necessary for further strategy.

Transarterial Embolization for Large Hepatocellular Carcinoma with Use of Superabsorbent Polymer Microspheres: Initial Experience

The authors report the initial experience with transarterial embolization of large hepatocellular carcinoma (HCC) with use of superabsorbent polymer microsphere (SAP-MS) particles. Six patients with nine HCCs (mean diameter, 8.2 cm) underwent 10 embolization procedures. Two patients underwent surgery later. In follow-up, tumor necrosis, postembolization syndrome, and laboratory data were assessed. Complete necrosis in three nodules, nearly complete necrosis in three nodules, and partial necrosis in three nodules were observed. Histologically, SAP-MS occluded intratumoral vessels tightly without ischemic damage of normal hepatic tissue. Postprocedural pain was minimal. No deterioration of liver function occurred. Our initial experience suggests that embolization with use of SAP-MS leads to extensive tumor necrosis of large nodular HCC, sparing use of chemotherapeutic agents.

Post-Kidney Transplantation Iliac Artery Stenosis due toIatrogenic Injury: Case Report

AbstractWe report a case of left external iliac artery lesions as a complication of post-kidney transplantation due to vascular clamp application injury. The lesions were proximal stenosis and distal occlusion just near the graft anastomosis site and they were diagnosed incidentally during the embolization for arteriovenous fistula. Angiography confirmed the diagnosis and it was managed successfully by percutaneous interventional techniques.

Detection of hypervascular hepatocellular carcinoma with dynamic magnetic resonance imaging with simultaneously obtained in-phase and opposed-phase echo images.

Purpose The technique of double-phase echo chemical shift gradient–echo magnetic resonance (MR) imaging with the fast low-angle shot sequence (double-echo FLASH) provides in-phase and opposed-phase (double-phase) images simultaneously. The purpose of this study was to assess whether the dynamic study with a combination of in-phase and opposed-phase (double-phase) echo images improves the detectability of hypervascular hepatocellular carcinoma (HCC) compared with that with either in-phase or opposed-phase images alone. Method Thirty-seven patients with 107 hypervascular HCCs who underwent the whole-liver double-phase echo dynamic MR imaging were enrolled in the study. Three radiologists blindly read in-phase images alone, opposed-phase images alone, and then double-phase images together. Sensitivity and positive predictive values as well as the areas below the alternative-free response receiver operating characteristic curve (Az values) for each imaging technique were calculated and compared statistically. Results The mean sensitivity, positive predictive values, and Az values for hypervascular HCCs were 51%, 77%, and 0.52 for in-phase imaging; 55%, 86%, and 0.58 for opposed-phase imaging; and 57%, 84%, and 0.63 for double-phase imaging, respectively. The mean sensitivity for opposed-phase imaging was significantly higher than that for in-phase imaging (P < 0.05), and the mean sensitivity for double-phase imaging was higher than that for in-phase imaging (P < 0.01). The mean Az value for the double-phase imaging was significantly higher than that for in-phase imaging (P < 0.01). Conclusion Dynamic MR imaging with double-phase images was recommended for the detection of hypervascular HCC.

A case of generalised oedema secondary to uterine artery embolisation for leiomyomata

Uterine artery embolisation is an alternative to hysterectomy, myomectomy or medical therapy for leiomyomata. Most reports suggest that it is well-tolerated and effective, – 8 although there have been several reports of serious complications. – 12 We present a case of severe oedema secondary to uterine artery embolisation for leiomyoma. A 41 year old nulliparous woman presented with symptomatic uterine leiomyomata causing abdominal distention and anaemia. Magnetic resonance imaging revealed an intramural posterior leiomyoma measuring 13 12 10 cm and many small nodules measuring 2 to 4 cm in diameter. She underwent bilateral uterine artery embolisation, using approximately 500–700 Am superabsorbent polymer microsphere particles as the embolic agent. During the procedure, which took about 2 hours, the total infusion was 380 mL and the urine output was 200 mL. After the procedure, the infusion was kept at 80 mL/h and she was allowed to drink. During the first 2 hours after the procedure, the urine output was 50 mL/h and during the next 4 hours it was 20 mL/h. The patient was managed with intravenous hydration (500 mL of lactated Ringer’s solution in 30 min) and frusemide administration (total 20 mg). The urine output was improved (140 mL/h during the following 4 hours). She was allowed to drink water freely (over 50 mL/h). The cause of the oliguria was unknown, so we continued the infusion at 80 mL/h and the urine output continued to be over 50 mL/mL. The following day, she developed enlargement of the lower abdomen and generalised oedema involving the face, body and extremities. There was no rash and she did not complain of any bowel symptoms. The uterus was slightly enlarged and soft. Abdominal ultrasonography revealed a small volume of ascites only. The serum urea and creatinine levels were within normal limits. The urine output gradually increased on the second day and the intravenous infusion stopped after 56 hours. The oedema peaked on day 2 (Fig. 1). We speculated that vascular permeability was increased due to a high vascular endothelial growth factor (VEGF) level produced by the ischaemic leiomyoma. We measured this using the human quantitative VEGF enzyme-linked immunosorbent assay (R&D Systems, Minneapolis, MN) (Fig. 1). This assay detects the free isoforms VEGF121 and VEGF165, for which plasma mean values of 42 (22) pg/mL in healthy subjects have been reported. EDTA-treated plasma was collected and stored at below 20jC until the assay. As we had already collected and stored a sample before uterine artery embolisation ( day 1 in Fig. 1) for other research purposes, we used this sample as the control before uterine artery embolisation. We detected an increase of plasma VEGF on day 1 after uterine artery embolisation

Evaluation of coronary artery bypass grafts using multidetector-row CT with Japanese patients

PurposeTo evaluate the patency of coronary artery bypass grafting (CABG) with multidetectorrow computed tomography (MDCT) in Japanese patients, who have narrower coronary arteries than Caucasians.Materials and MethodsNineteen patients (12 men and 7 women, mean age: 63±12 years) with 33 coronary bypass grafts were examined with three-dimensional volume rendering (3D-VR) and curved multiplanar reconstruction (MPR) of MDCT. All grafts were compared with those obtained with selective graft angiography.ResultsFor the 19 patients with 33 grafts, the overall sensitivity and specificity, compared with those for selective bypass angiography, were 96.7% and 100%, respectively.ConclusionThe patency of CABG in Japanese patients can be effectively evaluated with 3D-VR and curved MPR of MDCT.