Kevin C. Ching

Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage

PURPOSE To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

Peroneal Arteriovenous Fistula and Pseudoaneurysm: An Unusual Presentation

Peroneal artery arteriovenous fistulas and pseudoaneurysms are extremely rare with the majority of reported cases due to penetrating, orthopedic, or iatrogenic trauma. Failure to diagnose this unusual vascular pathology may lead to massive hemorrhage or limb threatening ischemia. We report an interesting case of a 14-year-old male who presented with acute musculoskeletal pain of his lower extremity. Initial radiographs were negative. Further imaging workup revealed a peroneal arteriovenous fistula with a large pseudoaneurysm. After initial endovascular intervention was unsuccessful, the vessels were surgically ligated in the operating room. Pathology revealed papillary endothelial hyperplasia consistent with an aneurysm and later genetic testing was consistent with Ehlers-Danlos syndrome Type IV. This case illustrates an unusual cause of acute atraumatic musculoskeletal pain and uncommon presentation of Ehlers-Danlos syndrome.

Endovascular Management of Massive Hemoptysis in Patients With Pulmonary Pseudosequestration

Idiopathic chronic lung consolidation is a rare cause of massive hemoptysis. We describe 2 patients with chronic pulmonary consolidation of unknown etiology who presented with massive hemoptysis resulting in airway compromise. Selective angiography demonstrated multiple hypertrophied systemic arteries supplying the area of consolidation, consistent with pulmonary pseudosequestration. Initial endovascular management with embolization resulted in immediate control of hemoptysis. Short interval repeat angiography and embolization was necessary in both patients to treat recurrent hemoptysis secondary to hemorrhage from multiple feeding arteries. Selective bronchial and nonbronchial systemic arterial embolization is an effective treatment for massive hemoptysis secondary to pulmonary pseudosequestration.

Wireless Connection between Guide Wires and Bone Cement: Extravasated Methyl Methacrylate Mimicking a Retained Guide Wire

We present the case of a 56-year-old double lung transplant recipient with chest pain who underwent an attempted endovascular retrieval of what was described as a retained guide wire in the azygos vein. After successfully grasping the tip, the object further migrated to the right pulmonary artery complicating the retrieval. It was realized that the “wire” was extravasated methyl methacrylate from a recent percutaneous kyphoplasty. This is believed to be the first report of attempted endovascular retrieval of extravasated methyl methacrylate in the azygos system. We include the details of this case and briefly review the current literature on the management of extravasated methyl methacrylate from vertebral augmentation procedures. Extravasated methyl methacrylate in the venous system is a common finding after vertebral augmentation procedures and any radiopaque stripe arising from a cemented vertebral body should be first described as probable cement leakage.