Keerati Hongsakul

Outcome and predictive factors of successful transarterial embolization for the treatment of acute gastrointestinal hemorrhage

Background Transarterial embolization (TAE) is an effective procedure for the treatment of acute gastrointestinal bleeding (GIB). Factors associated with clinical success have not been well delineated. Purpose To evaluate the technical and clinical successes of TAE for acute GIB in order to identify factors influencing clinical success and in-hospital mortality. Material and Methods This was a retrospective study of 70 consecutive patients with GIB who underwent angiography and embolization between January 2004 and December 2011. The technical success rate, clinical success rate, and in-hospital mortality were calculated by percentage. Clinical parameters, angiographic, and embolization data were assessed for factors influencing clinical success and in-hospital survival using univariate and multivariate analysis. Statistical significance was set at P value <0.05. Results The technical success rate was 98.6%. The primary clinical success rate was 71.4% and the secondary clinical success rate after repeat embolization was 78.6%. Bowel infarction was the most serious complication of three (4.3%) patients. Failure to achieve 30-day hemostasis can be predicted in patients who have one or more of the following factors: hemoglobin concentration <8 g/dL (P = 0.004), coagulopathy (P = 0.005), upper GIB (P = 0.02), contrast extravasation (P = 0.012), and more than one embolized vessel (P = 0.005). In-hospital survival is affected by the amount of transfused packed red blood cells before embolization (P = 0.008) and post-embolization bowel infarction (P = 0.005). Conclusion TAE is a feasible and effective management of acute GIB with high technical and clinical success rates. The factors influencing clinical success include hemoglobin concentration, coagulopathy, upper GIB, contrast extravasation, and more than one embolized vessel. The number of units of transfused packed red blood cells and post-embolization bowel infarction are important factors associated with in-hospital mortality.

Spontaneous Massive Hemothorax in a Patient with Neurofibromatosis Type 1 with Successful Transarterial Embolization

Vascular involvement in neurofibromatosis type 1 is rare but has the potential to be fatal. We report a case of a patient with spontaneous rupture of a left intercostal artery aneurysm, which presented as a massive left hemothorax and was successfully treated by transarterial coil embolization.

The “dot-in-circle” sign in musculoskeletal mycetoma on magnetic resonance imaging and ultrasonography

This study aimed to present the ‘dot-in-circle’ sign, which indicates the typical magnetic resonance imaging (MRI) and ultrasonographic (USG) findings for mycetoma involving soft tissue and bone. A total of 8 cases with histopathological proof of mycetoma affecting the musculoskeletal system, and that were examined via MRI and/or coexistent diagnostic ultrasonography between 2004 and 2013 in Songklanagarind Hospital were included in this study. The ‘dot-in-circle’ sign on the MRI and USG images of all the patients was reviewed by two radiologists. The analytic method was descriptive. All cases of musculoskeletal mycetoma revealed the ‘dot-in-circle’ sign on MRI, which was seen as multiple, small, round- to oval-shaped hyperintense lesions separated and surrounded by a low-signal intensity rim (circle), and a tiny, central, low-signal focus (dot). An USG study was available in four patients, and all USG findings demonstrated the ‘dot-in-circle’ sign as a central hyperechoic area (dot) surrounded by hypoechoic tissue (circle). In conclusion, the ‘dot-in-circle’ sign is a typical feature on MRI and USG findings for the diagnosis of musculoskeletal mycetoma.

Transarterial embolization for the treatment of massive bleeding in gynecologic and obstetric emergencies: a single center experience

Delayed treatment of the massive bleeding in gynecologic and obstetric conditions can cause high morbidity and mortality. The aim of this study is to assess the angiographic findings and outcomes of transarterial embolization in cases of massive hemorrhage from underlying gynecological and obstetrical conditions. This is a retrospective study of 18 consecutive patients who underwent transarterial embolization of uterine and/or hypogastric arteries due to massive bleeding from gynecological and obstetrical causes from January 2006 to December 2011. The underlying causes of bleeding, angiographic findings, technical success rates, clinical success rates, and complications were evaluated. Massive gynecological and obstetrical bleeding occurred in 12 cases and 6 cases, respectively. Gestational trophoblastic disease was the most common cause of gynecological bleeding. The most common cause of obstetrical hemorrhage was primary post-partum hemorrhage. Tumor stain was the most frequent angiographic finding (11 cases) in the gynecological bleeding group. The most common angiographic findings in obstetrical patients were extravasation (2 cases) and pseudoaneurysm (2 cases). Technical and final clinical success rates were found in all 18 cases and 16 cases. Collateral arterial supply, severe metritis, and unidentified cervical laceration were causes of uncontrolled bleeding. Only minor complications occurred, which included pelvic pain and groin hematoma. Percutaneous transarterial embolization is a highly effective and safe treatment to control massive bleeding in gynecologic and obstetric emergencies.

A Severe Case of Median Arcuate Ligament Syndrome with Successful Angioplasty and Stenting

Median arcuate ligament syndrome (MAL) or celiac axis compression syndrome (CACS) is a rare etiology of chronic abdominal pain. Traditional treatment of this syndrome is surgery. We report a case of median arcuate ligament syndrome with a severe compression of the celiac trunk, which was successfully treated by angioplasty with stenting.

Pharmacomechanical Thrombolysis for the Treatment of Thrombosed Native Arteriovenous Fistula: A Single-Center Experience

Summary Background Native arteriovenous fistula is one of the important routes for hemodialysis patients because of increased long-term survival and preservation of quality of life. We reported on a single-center experience with using pharmacomechanical thrombolysis for the treatment of thrombosed native arteriovenous fistula. Material/Methods This was a retrospective study of 12 hemodialysis patients (8 males and 4 females) with 14 thrombosed distal forearm Brescia-Cimino radiocephalic fistulas who were referred for pharmacomechanical thrombolytic treatment in the intervention unit of the Radiology Department, from 1 January 2010 to 30 December 2011. Demographic data, technical success rates, clinical success rates and complications were evaluated. The patency was evaluated by Kaplan-Meier analysis. Results The technical and clinical success was found in 12 thrombosed fistulas. Only 3 procedures had minor complications including small amounts of adjacent soft tissue hematoma. There were no procedure-related major complications. The primary patency rates at 6 and 12 months were 67% and 50%. The secondary patency rates at 6 and 12 months were 75% and 67%. Conclusions Pharmacomechanical thrombolysis is a minimally invasive, effective, durable, and safe procedure for the treatment of thrombosed native arteriovenous fistula. This procedure can be considered as an alternative treatment for thrombosed dialysis fistulas.

Congenital Hepatic Arteriovenous Malformation Presenting with Severe Persistent Pulmonary Hypertension

Congenital hepatic arteriovenous malformation is a rarely seen vascular malformation with persistent pulmonary hypertension in neonates. The authors report a full-term female newborn presenting with intractable heart failure and respiratory distress soon after birth. Investigation by echocardiography showed severe persistent pulmonary hypertension of the newborn and patent ductus arteriosus. The hepatic angiogram revealed congenital hepatic arteriovenous malformation; therefore, secondary pulmonary artery hypertension complicated with ‘steal’ phenomenon was conclusively diagnosed.

Transarterial Embolization of a Renal Artery Aneurysm Concomitant With Renal Arteriovenous Fistula

Congenital renal artery aneurysm is uncommon. Moreover, renal artery aneurysm concomitant with a congenital renal arteriovenous fistula is extremely rare. Transarterial embolization is the first-line treatment for these conditions. We report a case of a patient with congenital renal artery aneurysm concomitant with a congenital renal arteriovenous fistula of the upper polar left renal artery which was successfully treated by transarterial embolization with coil, glue, and Amplatzer vascular plug.

Patient Radiation Dose in Neurointerventional Radiologic Procedure: A Tertiary Care Experience

Purpose Neurointerventional radiology procedures often require a long time to perform. Patient radiation dose is an important issue due to the hazards of ionizing radiation. The objective of this study was to measure the peak skin dose (PSD) and effective dose to estimate the deterministic and stochastic effects of a therapeutic interventional neuroradiologic procedure. Materials and Methods The cumulative dose (CD) and dose area product (DAP) were automatically recorded by a fluoroscopic machine and collected prospectively between April and November 2015. The study included 54 patients who underwent therapeutic neurointerventional radiology procedures. The CD of each patient was used to estimate the peak skin dose and the DAP was also calculated to estimate the effective dose. Results The average estimated peak skin dose was 1,009.68 mGy. Two patients received radiation doses of more than 2 Gy, which is the threshold that may cause skin complications and radiation-induced cataract. The average effective dose was 35.32 mSv. The majority of patients in this study (85.2%) who underwent therapeutic neurointerventional radiologic procedures received effective doses greater than 20 mSv. Conclusion Not all therapeutic neurointerventional radiology procedures are safe from deterministic complications. A small number of patients received doses above the threshold for skin complications and radiation induced cataract. In terms of stochastic complications, most neurointerventional radiology procedures in this study were quite safe in terms of radiation-induced cancer.

Paclitaxel-Coated Balloon Angioplasty for Early Restenosis of Central Veins in Hemodialysis Patients: A Single Center Initial Experience

Objective To report the results of angioplasty with paclitaxel-coated balloons for the treatment of early restenosis of central veins in hemodialysis patients. Materials and Methods Sixteen patients (9 men and 7 women; mean age 65.8 ± 14.4 years; range, 40–82 years) with 16 episodes of early restenoses of central veins within 3 months (median patency duration 2.5 months) were enrolled from January 2014 to June 2015. Ten native central veins and 6 intra-stent central veins were treated with double paclitaxel-coated balloons (diameter 6–7 mm) plus a high pressure balloon (diameter 12–14 mm). The study outcomes included procedural success (< 30% residual stenosis) and primary patency of the treated lesion (< 50% angiographic stenosis without re-intervention). Results Procedural success was achieved in all 16 cases of central vein stenoses. The mean diameter of the central vein was 3.7 ± 2.4 mm before the procedure vs. 11.4 ± 1.8 mm after the initial procedure. There were no procedure-related complications. The mean diameters of the central veins at 6 months and 12 months were 7.8 ± 1.3 mm and 6.9 ± 2.7 mm, respectively. The primary patency rates at 6 months and 12 months were 93.8% and 31.2%, respectively. One patient had significant restenosis of the central vein at 3 months. The median primary patency period was 9 months for paclitaxel-coated balloons and 2.5 months for the last previous procedure with conventional balloons (p < 0.001). Conclusion In our limited study, paclitaxel-coated balloons seem to improve the patency rate in cases of early restenosis of central veins. However, a further randomized control trial is necessary.