Carlos Abath

Complex Renal Artery Aneurysms: Liquids or Coils?

Although renal aneurysms are considered uncommon lesions, they are being disclosed more often with the increasing use of noninvasive imaging diagnostic methods. As the natural history is poorly defined, criteria for treatment are still controversial. Because it is less invasive, the endovascular treatment of renal artery aneurysms has become preferable to surgery, over recent years. The development of microcatheter-guidewire systems and new embolic materials, primarily used in interventional neuroradiolgy, enables a superselective embolization, even in complex lesions. We describe our experience in 11 complex renal artery aneurysms, using platinum detachable coils, liquid embolic agents (glue and Onyx), and remodeling technique, according to the lesion architecture and topographic classification. Complete durable occlusion was obtained in all cases, with only two minor complications. If an appropriated strategy is done and the tools are available, the endovascular approach currently is the first treatment option for renal artery aneurysms.

Cateteres intravenosos fraturados: retirada por técnicas endovasculares

OBJECTIVE: Central venous access is an increasingly frequent procedure and intravenous catheter fractures and fragments embolization, although being rare, correspond to the most common intravascular foreign bodies. This study purpose is to show our experience in the removal of these foreign bodies, employing endovascular techniques. MATERIALS AND METHODS: Retrospective analysis of ten consecutive cases in the last five years, including patients with ages ranging from 9 months to 67 years. RESULTS: The procedure was successfully performed in all the cases by means of different techniques and with no complication. Most common fragments lodgement sites were: right atrium, superior vena cava and left pulmonary artery. The retrieval of these foreign bodies by means of endovascular techniques is a relatively simple procedure when compared to the surgical alternative, and has been safely and successfully performed in countless patients. The available devices have proven quite effective and, among them, the loop snare is the most versatile. CONCLUSION: The high success rate with few complications reported, even in children, allows us to say that, whenever possible, percutaneous extraction of intravascular foreign objects should be performed. Notwithstanding, familiarization with the several techniques available is essential, allowing combinations and modifications according to each situation.

Endovascular treatment of traumatic carotid cavernous fistula with balloon-assisted sinus coiling. A technical description and initial results.

This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a “U-turn” maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe.

Dissecting anterior inferior cerebellar artery aneurysm treated by endovascular route: report of three cases and review.

ANGIORAD, Interventional Radiology, Hospital Santa Joana, Recife PE, Brazil: Interventional Radiologist, Scientific Director of ANGIORAD; Neurosurgeon, Hospital da Restauração, Recife PE, Brazil; Chaiman of the Department of Neurosurgery, Hospital da Restauração, Recife PE, Brazil; Resident of Neurosurgery, Hospital da Restauração, Recife PE, Brazil; Resident of Interventional Radiology, ANGIORAD; Interventional Radiologist, Chairman of ANGIORAD. Among the major arteries of the posterior fossa, the anterior inferior cerebellar artery (AICA) is the least likely to harbor an aneurysm, being a very rare pathology. Only two AICA aneurysms were found in 7,933 lesions. In the presence of a high flow lesion, aneurysms tend to occur more commonly in the feeding arteries. These flow-related aneurysms in the posterior fossa can be found mainly associated with arteriovenous malformations (AVM) or hemangioblastomas, which represents the majority of AICA aneurysms reported. For eight years, 1,450 aneurysms were seen in a single-center, with only two AICA aneurysms, both flow-related (AVM). Aside from flow-related aneurysms, almost all distal AICA aneurysms are dissecting aneurysms, usually presenting in otherwise healthy adults. Again the AICA is the least likely to present an isolated dissection among the major arteries. We report three cases of “spontaneous” AICA dissection aneurysms.

Impact of pelvic magnetic resonance imaging findings in the indication of uterine artery embolization in the treatment of myoma

OBJECTIVES To assess the impact of pelvic magnetic resonance imaging (MRI) findings in the indication for uterine-artery embolization in women with fibroids, as well as the correlation between MRI and ultrasound (US) examinations for diagnosing adenomyosis. MATERIAL AND METHODS A retrospective observational study was performed through the analysis of the medical records of 263 women referred for uterine-artery embolization as treatment for fibroids after undergoing US and MRI examinations. To compare uterine volume and fibroid measurement in US and MRI, the Wilcoxon test was used; for the number of fibroids, the McNemar test was used. The kappa coefficient was used to evaluate the correlation between US and MRI findings for diagnosing adenomyosis. RESULTS The mean age of patients was 37.9 ± 6.8 years and 191 (72.6%) were nulliparous. Forty-three patients with adenomyosis associated with fibroid were diagnosed by MRI; US indicated the presence of adenomyosis in 12 (4.56%) women. There was agreement between MRI and US in the diagnosis of adenomyosis in 218/263 (82.9%) patients (p < 0.05). In the US examination, the mean uterine volume was lower (389 ± 340.8 cm³) than that observed in MRI (472.2 ± 415.9 cm³; p < 0.001). Regarding the number of fibroids, MRI showed a greater number of patients with multiple fibroids (68.8% vs. 57.4%, MRI and US, respectively; p < 0.001). CONCLUSIONS In women with fibroids referred for uterine-artery embolization, MRI findings led to the revision of the initial diagnosis in 17.1% cases. US showed a lower sensitivity for diagnosing adenomyosis than MRI.

Dural arteriovenous fistulas: unusual access routes in the elderly.

Transvenous embolization is effective in the treatment of an intracranial dural arteriovenous fistula (DAVF). Retrograde venous access to the fistula may be limited by associated sinus thrombosis, as in the two cases here reported. Unusual curative access routes were performed: direct superior ophthalmic vein puncture and through a small craniectomy, packing the sinus with detachable coils. When traditional routes proved impossible, unusual access routes must be devised.

A importância da embolização pré-operatória no tratamento do tumor do corpo carotídeo: relato de caso e revisão da literatura

Os tumores do corpo carotideo sao neoplasias raras, que se originam dos pequenos orgaos quimio e barorreceptores localizados na adventicia da bifurcacao da arteria carotida comum. Constituem-se uma doenca de grande interesse para o cirurgiao vascular, na medida em que crescem aderidos a adventicia dos vasos que compoem essa bifurcacao. Por isso, sua cirurgia requer nao so o conhecimento anatomico da regiao, mas tambem perfeito reconhecimento das tecnicas de reconstrucao vascular. Representam um problema especial quanto a seu manejo, devido a sua rica vascularizacao e intimidade com estruturas nobres da regiao cervical, como nervos e grandes vasos. Neste caso, apresentamos um homem com um tumor de corpo carotideo aderido a carotida direita, diagnosticado por puncao biopsia e tratado em dois tempos, sendo o primeiro por tratamento endovascular, realizando embolizacao percutânea do tumor, e, no segundo, a resseccao cirurgica do mesmo, o que evidencia o tratamento combinado, segundo atual literatura.

Resposta do ACTH plasmático ao estímulo com CRH ou CRH + desmopressina em pacientes com síndrome de Cushing ACTH- dependente submetidos a cateterismo bilateral simultâneo dos seios petrosos inferiores

OBJECTIVE: To compare the responses of plasmatic ACTH to CRH or combined CRH/desmopressin stimulation in patients with ACTH-dependent Cushings syndrome submitted to simultaneous, bilateral inferior petrosal sinuses sampling. MATERIALS AND METHODS: The procedure was performed in 21 patients - 14 women and 7 men - diagnosed with ACTH-dependent Cushings syndrome in the period between January 1998 and December 2003. Upon catheterization of both inferior petrosal sinuses, blood samples for ACTH test were simultaneously collected from the petrosal sinuses and peripheral vein, both in the basal state and three to five minutes after injection of human CRH (100 mg) (six patients), or combined CRH/desmopressin (100 mg + 10 mg) (15 patients). RESULTS: After three minutes, both groups presented increased ACTH levels: CRH (257.77 ± 240.36 in the right petrosal sinus, and 718.78 ± 1358.82 in the left petrosal sinus [mean ± standard error]); combined CRH/desmopressin (1263.35 ± 1842.91 in the right petrosal sinus [p = 0.06], and 583.93 ± 1020.03 in the left petrosal sinus [p = 0.83]). After five minutes, the ACTH levels decreased in the group with CRH (181.07 ± 217.39 in the right petrosal sinus, and 188.25 ± 270.15 in the left petrosal sinus), and presented a progressive increase in the group with combined CRH/desmopressin (1365.29 ± 1832.31 in the right petrosal sinus [p = 0.03], and 866.43 ± 1431.72 in the left petrosal sinus [p = 0.11]). Gradient was absent in the three patients with ectopic secretion. CONCLUSION: Combined CRH/desmopressin stimulation induced a higher production of ACTH in cases of corticotroph adenomas as compared with CRH stimulation, which can improve the diagnostic sensibility of this procedure.