Bora Peynircioglu

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.

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.

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.

Bronchial to Coronary Artery Fistulas: An Important Sign of Silent Coronary Artery Disease and Potential Complication during Bronchial Artery Embolization

Coronary artery fistulas are rare and usually asymptomatic congenital anomalies generally diagnosed incidentally during coronary angiographies. Herein, we present a case of bronchial to coronary artery fistula which was diagnosed incidentally during bronchial artery embolization. Embolization was performed successfully without complication, and an underlying important coronary artery stenosis was subsequently found by coronary computed tomography angiography.

Radioembolization for the treatment of unresectable liver cancer: initial experience at a single center.

PURPOSE Radioembolization with yttrium-90 microsphere (Y-90) therapy with SIR-Spheres (Sirtex Medical, Lane Cove, Australia) was approved by the Turkish Ministry of Health in April 2008. In this study, we present the preliminary experience at a tertiary care center with early follow-up results of Y-90 therapy, as well as a review of the related literature. MATERIALS AND METHODS Complete evaluation for radioembolization was performed in 10 patients (8 males, 2 females; mean age, 52.3 years) during an 8-month period at a single center, of which 9 were actually treated with SIR-Spheres(R). All patients underwent meticulous pre- and post-procedural imaging studies to document the therapy response. RESULTS; In order to isolate the target hepatic arterial circulation, following branches were embolized as they were considered as potential gastrointestinal shunts: the gastroduodenal artery (n = 5), right gastric artery (n = 1), and supraduodenal artery (n = 1). Radioembolization therapy could not be performed only in one patient because of a hepatogastric shunt of unknown origin. No significant hepatopulmonary shunting was identified (maximum, 9% shunting). The body surface area method was used to calculate the Y-90 dose in all patients (mean dose, 1.24 GBq). All patients had at least partial response of the targeted liver lesions, according to RECIST (Response Evaluation Criteria in Solid Tumors). CONCLUSION In comparison to chemoembolization, radioembolization has less systemic toxicity and can be performed as an outpatient procedure, which makes it more attractive to both patients and physicians. From our limited experience, the radioembolization procedure is a promising first-line treatment in unresectable liver cancer; randomized controlled multi-center studies, however, are needed.

Neuroapplication of Amplatzer vascular plug: a novel device for parent artery occlusion

Extracranial internal carotid aneurysms are rare, but the complications associated with the traditional surgical reconstruction methods are relatively high. Endovascular treatment has replaced surgery for treatment of a variety of vascular problems. We describe here the treatment of a recurrent extracranial internal carotid artery aneurysm using a detachable balloon combined with the Amplatzer vascular plug.

Exclusion of Atherosclerotic Plaque from the Circulation Using Stent-Grafts: Alternative to Carotid Stenting with a Protection Device?

PurposeTo retrospectively assess the feasibility, safety, and clinical mid-term outcome of patients undergoing carotid artery stenting with stent-grafts.MethodsOver a 4 year period stent-grafts were used in the endovascular treatment of symptomatic internal carotid artery stenosis in 12 patients (2 women, 10 men, aged 47–83 (mean 64) years). Protection devices were not used. Possible microembolic complications were evaluated by magnetic resonance imaging (MRI) examinations of the brain before and the day after the procedure in all patients. Mean follow-up was 22 months (range 1–42 months), by Doppler ultrasonography and conventional angiography as well as clinical examination.ResultsThe technical success rate was 100%. A total of 13 coronary stent-grafts were used. The mean stenosis rate (in terms of diameter) was 85% and the mean length of stent-grafts used was 20.9 mm. The mean diameter to which the stent-grafts were dilated was 4.66 mm. In-hospital complications occurred in 1 patient who suffered a minor femoral access hematoma that did not require transfusion or surgical decompression. Post-stenting diffusion-weighted MRI revealed several ipsilateral silent microemboli in only 1 case, which was completely asymptomatic. Two patients had a major stroke after 2 years of follow-up. Restenosis was found in 2 patients who underwent successful balloon dilatation followed by placement of a self-expandable bare stent within the stent-grafts.ConclusionsStent-grafts may prevent microembolic complications during stenting of atherosclerotic carotid lesions in selected cases, offering immediate exclusion of the atherosclerotic lesion from the circulation by pressing the plaque against the vessel wall. Comparative, randomized studies in larger series of patients are needed with carotid-dedicated stent-graft designs.

Bleeding pulmonary artery pseudoaneurysm secondary to squamous cell lung cancer: computed tomography findings and endovascular management

A case of bleeding pulmonary artery pseudoaneurysm secondary to squamous cell lung cancer is reported. The patient presented with massive hemoptysis, diagnosis was made with multidetector computed tomography, and the pseudoaneurysm was successfully embolized with platinum coils. Hemoptysis ceased following the procedure.