F. Scott Nowakowski

Inferior Mesenteric Artery Embolization before Endovascular Aneurysm Repair: Technique and Initial Results

PURPOSE To report a single centers technique and initial results in the preoperative embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR). MATERIALS AND METHODS Over a 3-year period, 102 patients at a single clinical site, including 86 men and 16 women aged 54-93 years (mean, 75 years), were found to have a patent IMA on computed tomographic (CT) angiography before EVAR. Coil embolization was performed after subselective catheterization with use of microcoils placed in the IMA proximal to the origin of the left colic artery. All patients in whom the IMA was visualized on flush aortography and successfully accessed underwent embolization. One month and 6 months after surgery, results in this cohort were retrospectively compared with those from a similar group of patients who underwent EVAR during the same period. These patients had patent IMAs on preoperative CT angiography but did not undergo embolization as a result of nonvisualization during flush aortography. All patients underwent EVAR with bifurcated modular devices with proximal transrenal fixation. All patients underwent postoperative follow-up with multiphase CT angiography to detect the presence of endoleak. Six-month follow-up data were available for 18 patients who underwent embolization and 54 patients who did not. Change in sac diameter was compared in these patients. RESULTS Embolization was technically successful in 30 of 32 patients (94%) in whom it was attempted. There were no complications. At 1-month follow-up, five of 30 patients in the embolization group were noted to have a type II endoleak (17%). None of the endoleaks in this group were related to the IMA. The group with patent IMAs who did not undergo preoperative embolization had a 42% incidence of type II endoleak (P < .05). At 6 months after surgery, three of 18 patients who had undergone embolization (17%) had a type II endoleak, compared with 26 of 54 in the other group (48%; P < .05). Among the patients in whom 6-month data were available, mean changes in sac diameter were -5.2 mm (range, -24 to 2 mm) in the embolized group and -2.1 mm (range, -19 to 8 mm) in the nonembolized group. CONCLUSION These initial results demonstrate that embolization of the IMA with subselective microcoils before EVAR is a safe and effective procedure to reduce the incidence of type II endoleaks. The data also suggest that preoperative embolization of the IMA is associated with greater shrinkage of aneurysm sac diameter at 6 months.

Uterine artery embolization using a transradial approach: initial experience and technique

This study investigates the feasibility of performing uterine artery embolization (UAE) via transradial access (TRA). Growing evidence demonstrates significant benefits of TRA versus standard transfemoral access during percutaneous coronary intervention, now making it the preferred approach at many centers worldwide. At a single institution from March 2013 to October 2013, 29 consecutive patients were treated by transradial UAE. Technical success rate was 100%, with no immediate major or minor complications. The radial artery was patent at 1-month follow-up evaluation in all cases. These preliminary data suggest that transradial UAE is feasible and safe.

Single-Center Experience with Elective Transcatheter Coil Embolization of Splenic Artery Aneurysms: Technique and Midterm Follow-up

PURPOSE To review a single-center experience with elective coil embolization of splenic artery aneurysm (SAA) and analyze efficacy of the technique at midterm follow-up. MATERIALS AND METHODS From 2002 through 2011, 50 patients (28 women, 22 men; age range, 24-89 y; mean age, 53.5 y ± 13.6) underwent transcatheter coil embolization for treatment of SAAs. Pseudoaneurysms and ruptured aneurysms were excluded. A total of 63 SAAs were treated (size, 13-97 mm; mean, 29 mm). Ninety-eight percent of aneurysms were treated with coils alone. Regular follow-up consisted of an office visit and imaging. Patient medical records were reviewed for aneurysm location, procedural approach, and technical and clinical outcomes. RESULTS Ninety-eight percent of procedures were technically successful at thrombosing the aneurysm at the time of procedure. Repeat intervention was performed in four of 47 patients (9%) because of continued aneurysm perfusion at follow-up. Mean time to repeat intervention was 125 days (range, 42-245 d). All repeat interventions were technically successful. Neither aneurysm growth nor aneurysm rupture was observed in any patient during the follow-up period (mean, 78 weeks; range, 9 d to 7.1 y). There were no major adverse events. Major splenic infarction occurred in three of 33 patients (9%) with no underlying liver disease and normal splenic volume and in seven of 14 patients (50%) with portal hypertension. CONCLUSIONS Percutaneous transcatheter coil embolization is a safe, effective, and minimally invasive treatment for SAAs as evidenced by high rates of technical success and freedom from aneurysm rupture.

Aortic intimal dehiscence: a complication of percutaneous balloon fenestration for aortic dissection.

A patient with acute type B dissection and a tube configuration of the intimal flap presented with signs of advanced mesenteric and renal ischemia as well as decreased pulses in the lower extremities. The patient was referred for emergency percutaneous fenestration of the abdominal aorta as a salvage procedure and a possible bridge to later surgery. After fenestration, femoral pulses became transiently stronger and then disappeared. The patient died after exploratory laparotomy. Postmortem examination demonstrated dehiscence of the infrarenal abdominal aortic intima with occlusion of the aortic bifurcation.

Prospective, Randomized Study of Coil Embolization versus Surefire Infusion System during Yttrium-90 Radioembolization with Resin Microspheres

PURPOSE To compare standard coil embolization versus the use of an antireflux microcatheter (ARM) in patients undergoing planning angiography before selective internal radiation therapy (SIRT). MATERIALS AND METHODS A prospective, single-center trial was performed in which 30 patients were randomly assigned to undergo SIRT with coil embolization or the use of an ARM. The coil group underwent detachable coil embolization of nontarget vessels, and the ARM group underwent infusion of macroaggregated albumin with use of an ARM system, without coil embolization. Single-photon emission computed tomography (CT)/CT was then performed to assess for nontarget distribution. The primary endpoint was fluoroscopy time during planning angiography. Secondary endpoints included deployment time, total procedure time, radiation dose-area product, contrast agent used, and adverse events. Endpoints were evaluated during planning angiography and SIRT. RESULTS Over a 9-month period, 30 consecutive patients were randomized at a 1:1 ratio between coil embolization and ARM groups. Technical success rates were 100% in both groups. Mean fluoroscopy time was significantly reduced in the ARM group versus the coil embolization group (1.8 min [range, 0.4-4.9 min] vs 6.0 min [range, 1.9-15.7 min]; P = .002). The planning procedure time (P < .001), deployment time (P < .001), dose-area product (P = .04), and amount of contrast agent used (P < .001) were also significantly less in the ARM group than in the coil embolization group. No nontarget distribution was detected in either group. There was no difference between groups in dose delivered on the day of SIRT (P = .71). There were no major or minor adverse events at 30 days. CONCLUSIONS The use of an ARM during planning angiography can significantly reduce fluoroscopy time, procedure time, and radiation dose.

Portal Vein Embolization before Right Hepatectomy or Extended Right Hepatectomy Using Sodium Tetradecyl Sulfate Foam: Technique and Initial Results

PURPOSE To evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam. MATERIALS AND METHODS A single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded. RESULTS PVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively. CONCLUSIONS Preoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Percutaneous Microwave Ablation of Renal Tumors Using a Gas-Cooled 2.4-GHz Probe: Technique and Initial Results

The feasibility, safety, and preliminary effectiveness of microwave ablation (MWA) in the treatment of renal tumors using a high-powered, carbon dioxide-cooled probe were evaluated. There were 15 tumors treated in 14 patients. Computed tomography was performed immediately after MWA, and follow-up imaging was performed to evaluate for recurrence. Immediate technical effectiveness was 100%. One complication involved the formation of a renal artery pseudoaneurysm. At follow-up (mean interval, 12.5 wk) evaluation, 14 of 15 (93.3%) tumors demonstrated complete necrosis. MWA is a safe, effective treatment modality; larger studies are warranted to demonstrate long-term oncologic outcomes.

Intra-arterial Methylprednisolone Infusion in Treatment-Resistant Graft-Versus-Host Disease

Acute graft-versus-host disease (GVHD) is a potentially fatal complication following allogeneic hematopoietic stem cell transplant. Standard primary therapy for acute GVHD includes systemic steroids, often in combination with other agents. Unfortunately, primary treatment failure is common and carries a high mortality. There is no generally accepted secondary therapy for acute GVHD. Although few data on localized therapy for GVHD have been published, intra-arterial injection of high-dose corticosteroids may be a viable option. We treated 11 patients with steroid-resistant GVHD using a single administration of intra-arterial high-dose methylprednisolone. Three patients (27%) died periprocedurally. Four patients (36%) had a partial response to intra-arterial treatment and were discharged on total parenteral nutrition and oral medication. Four patients (36%) had a complete response and were discharged on oral diet and oral medication. No immediate treatment or procedure-related complications were noted. Twenty-seven percent of patients survived long-term. Our preliminary results suggest that regional intra-arterial treatment of steroid-resistant GVHD is a safe and potentially viable secondary therapy in primary treatment-resistant GVHD.

TIPS for Refractory Ascites: A 6-Year Single-Center Experience With Expanded Polytetrafluoroethylene -Covered Stent-Grafts

OBJECTIVE. This single-center study evaluated the use of expanded polytetrafluoroethylene (ePTFE)-covered stent-grafts for transjugular intrahepatic portosystemic shunt (TIPS) placement to manage portal hypertension-related refractory ascites. MATERIALS AND METHODS. One hundred patients at a single tertiary care center in a major metropolitan hospital underwent TIPS placement with an ePTFE-covered stent-graft (Viatorr TIPS Endoprosthesis). Patients with portal hypertension-related ascites and preexisting hepatocellular carcinoma or liver transplant were excluded from the analysis. Records were reviewed for demographic characteristics, technical success of the TIPS procedures, and stent follow-up findings. Clinical results were assessed at 90- and 180-day intervals. RESULTS. Immediate technical success of the TIPS procedure was 100%. Of the 61 patients with documented follow-up, 55 (90.2%) had a partial or complete ascites response to TIPS creation. Of these 55 patients, nine experienced severe encephalopathy. Six of 61 patients (9.8%) did not experience a significant ascites response. Overall survival was 78.7% at 365-day follow-up. The 365-day survival was 84.2% for patients with a model for end-stage liver disease (MELD) score of less than 15, 67.0% for those with a score of 15-18, and 53.8% for those with a score of greater than 18 (p = 0.01). For patients with a MELD score of less than 18, the 365-day survival was 88.0% for those with an albumin value of 3 mg/dL or greater and 72.8% for those with an albumin value of less than 3 mg/dL (p = 0.04). CONCLUSION. TIPS placement using an ePTFE-covered stent-graft is an efficacious therapy for refractory ascites. Patients with preserved liver function-characterized by a MELD score of less than 15 or a MELD score of less than 18 and an albumin value of 3 mg/dL or greater-experience the greatest survival benefit.

Percutaneous Mesocaval Shunt Creation in a Patient with Chronic Portal and Superior Mesenteric Vein Thrombosis

AbstractThe creation of a transjugular intrahepatic portosystemic shunt (TIPS) is a critical procedure for the treatment of recurrent variceal bleeding and refractory ascites in the setting of portal hypertension. Chronic portal vein thrombosis remains a relative contraindication to conventional TIPS and options are limited in this scenario. Presented is a novel technique for management of refractory ascites in a patient with hepatitis C cirrhosis and chronic portal and superior mesenteric vein thrombosis secondary to schistosomiasis and lupus anticoagulant utilizing fluoroscopically guided percutaneous mesocaval shunt creation.