Barbaros Cil

Embolization of high-flow craniofacial vascular malformations with onyx.

BACKGROUND AND PURPOSE: Various techniques and materials have been used for the endovascular treatment of craniofacial high-flow arteriovenous vascular malformations, because their rarity precludes standardization of their treatment. The aim of this retrospective review is to assess Onyx as the primary embolic agent in the treatment of these vascular malformations. MATERIALS AND METHODS: Six patients with arteriovenous fistulas and 3 with arteriovenous malformations (AVMs) of the head and neck region were treated with intra-arterial (IA)/direct percutaneous injections of Onyx. Adjunctive maneuvers used during embolization included external compression of the arterial feeders or venous outflow (6 patients), balloon assist (4 patients), and direct embolization of the draining vein remote to the fistula site (1 patient). n-butyl-2-cyanoacrylate (n-BCA) was used in addition to Onyx for rapid induction of thrombosis in a large venous pouch (1 patient) and for cost containment purposes (1 patient). Four patients were treated surgically after the embolization. RESULTS: There were no neurologic complications secondary to the embolization procedure. The arteriovenous shunt was eliminated in all of the fistulous lesions and 2 of the 3 AVMs. The embolization was incomplete in 1 patient with a large AVM who declined further endovascular or surgical procedures. Untoward events included 2 instances of catheter entrapment (of 9 IA injections), blackish skin discoloration necessitating surgical revision in 1 patient, and difficulty of balloon deflation/wire withdrawal during a balloon-assisted embolization. CONCLUSION: Onyx appears to be a safe and effective liquid embolic agent for use in the treatment of craniofacial high-flow vascular malformations with distinct advantages and disadvantages compared with n-BCA.

Bilateral Multiple Pulmonary Arteriovenous Malformations: Endovascular Treatment with the Amplatzer Vascular Plug

Pulmonary arteriovenous malformation (AVM) is a rare vascular malformation of the lung that carries a considerable risk of serious complications such as cerebral embolism, brain abscess, and pulmonary hemorrhage. Embolization with coils or detachable balloons is currently the preferred treatment. Paradoxical embolization of coils and balloons may occur, especially in patients with large feeding arteries. This report describes an initial experience with the use of the Amplatzer Vascular Plug used for endovascular treatment of bilateral multiple pulmonary AVMs in an adult patient.

Percutaneous Drainage of 300 Intraperitoneal Abscesses with Long-Term Follow-Up

The purpose of the study was to evaluate the efficacy of percutaneous drainage of intraperitoneal abscesses with attention to recurrence and failure rates. A retrospective analysis of percutaneous treatment of 300 intraperitoneal abscesses in 255 patients (147 male, 108 female; average age: 38 years; range: 40 days to 90 years) for whom at least 1-year follow-up data were available was performed. Abscesses were drained with fluoroscopic, sonographic, or computed tomographic guidance. Nine abscesses were drained by simple aspiration; catheter drainage either by Seldinger or trocar technique was used in the remaining 291 abscesses with 6F to 14 F catheters. Initial cure and failure rates were 68% (203/300) and 12% (36/300), respectively. Sixty-one abscesses (20%) were either palliated or temporized. The recurrence rate was 4% (12/300) and nine of them were cured by recatheterization, whereas three of them were treated by medication or surgery. The overall success and failure rates were 91% (273/300) and 9% (27/300), respectively, with temporized, palliated, and recatheterized recurred abscesses. The 30-day mortality rate was 3.1% (8/255). The mean duration of catheterization was 13 days. Intraperitoneal abscesses with safe access routes should be drained percutaneously because of high success and low morbidity, mortality, and recurrence rates.

Endovascular Stent-Graft Applications in Iatrogenic Vascular Injuries

AbstractPurpose: To report the results of covered stent applications in iatrogenic vascular injuries. Methods: We report 17 patients (11 men, 6 women; age range 20–59 years, mean age 40 years) who underwent repair of different iatrogenic vascular lesions by means of endovascular covered stents. The patient population consisted of 8 femoral arteriovenous fistulae, 4 common femoral artery pseudoaneurysms, 1 subclavian artery pseudoaneurysm, 1 abdominal aortic aneurysm, 1 iliac artery perforation, 2 porto-biliary fistulae that developed during TIPS procedure. Balloon-expandable stent-grafts were used in all patients except one. Control studies were performed with angiography. Results: Technical success was achieved in all 17 patients. The mean clinical follow-up period for all 17 patients was 8 months. There were no signs of stent migration or leaks in the control studies. Only one patient developed a hemodynamically insignificant stenosis at the proximal end of the stent. There have been no stent deformations or related complications during the follow-up period. Conclusion: Our short-term results suggest that endovascular treatment is a low-risk procedure and appears less invasive than surgery for the treatment of different types of iatrogenic vascular injuries. Intermediate and long-term results are not available.

Renal Artery Pseudoaneurysm: Complication of Minimally Invasive Kidney Surgery

PURPOSE We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. MATERIALS AND METHODS In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. RESULTS In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. CONCLUSION There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

IntroductionWe evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.MethodsA total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.ResultsThe procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.ConclusionOur experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

Effect of use of slow release of bone morphogenetic protein-2 and transforming growth factor-Beta-2 in a chitosan gel matrix on cranial bone graft survival in experimental cranial critical size defect model.

Bone grafts, used for providing structural integrity of cranial vault remodeling, could not always integrate with the remaining bone structures. All efforts are focused on increasing incorporation of the applied bone grafts. Allografts were covered by chitosan so that slow release of bone morphogenetic protein-2 (BMP-2) and Transforming growth factor-beta-2 (TGF-beta-2) was achieved. Two hundred forty Wistar-Albino rats were distributed equally in 8 study groups. Study groups were designed as; defect group, autograft group, allograft group, chitosan group, allograft + chitosan, TGF-beta-2 group, BMP-2 group, and TGF-Beta-2 +BMP-2 group. Bone biopsies were obtained at second, eight, and 14th weeks. Bone regeneration was evaluated by morphologic studies detecting histologic bone healing and radiologic studies detecting bone density. Histologic findings were evaluated in 2 categories; tissue response to the implant and defect healing. Additionally, scanning electron microscopy for detailed morphologic evaluation was done. Bone density of the applied scaffold and the parietal bone at the same computed tomography section were measured in Hounsfield scale and this ratio was used for densitometry evaluations. Kruskal-Wallis test was used to analyze difference among groups according to the histologic and radiologic data. Pairwise comparisons were done using Mann-Whitney U test with Bonferroni correction. P < 0.05 was considered significant. In the morphologic studies, bone regeneration in BMP-2 group was found to be compatible with bone regeneration in gold standard autograft group and even better than it within 15 days. Chitosan is a biocompatible material. TGF-Beta-2 alone is not effective enough in bone regeneration; BMP-2 alone has a positive effect in every step of bone regeneration. Combining TGF-Beta-2 with BMP-2 does not lead to a better bone regeneration than using BMP-2 alone. A synergistic effect is not obtained by using these 2 factors together.

ENDOVASCULAR MANAGEMENT OF LIFE-THREATENING RETROPERITONEAL BLEEDING

Background:  The aim of this study was to evaluate efficiency of embolotherapy in management of retroperitoneal bleedings.

A rare complication of hemodialysis catheters: Superior vena cava syndrome

Central venous catheters in hemodialysis patients may result in superior vena cava (SVC) syndrome. With the increasing use of these catheters, the SVC syndrome will probably be more common among hemodialysis patients. This report describes 3 cases of SVC syndrome due to central venous catheters that developed in hemodialysis patients with previous multiple catheter placements.

Percutaneous Placement of Peritoneal Port-Catheter in Patients with Malignant Ascites

We report our experience with a radiologically placed peritoneal port-catheter in palliation of malignant ascites. Port-catheters were successfully placed under ultrasonographic and fluoroscopic guidance in seven patients (five women, two men) who had symptomatic malignant ascites. The long-term primary patency rate was 100%. The mean duration of catheter function was 148 days. Seven patients had a total of 1040 port-days. Two patients received intraperitoneal chemotherapy via the port-catheter. There were no procedure-related mortality and major complications. Minor complications such as ascitic fluid leakage from the peritoneal entry site, migration of the catheter tip to the right upper quadrant, and reversal of the port reservoir occurred in four patients. None of these complications affected the drainage and required port explantation. In patients with symptomatic malignant ascites, a peritoneal port-catheter can provide palliation and eliminate multiple hospital visits for repeated paracentesis with high patency and low complication rates.