Maysoon F. Hamed

Occlusion Time for Amplatzer Vascular Plug in the Management of Pulmonary Arteriovenous Malformations

OBJECTIVE The occlusion time, that is, the interval between device deployment and complete occlusion of the vessel, associated with the use of embolic devices influences the risk of embolic complications caused by small clots that can form over the surface of a device and break away. The purpose of our study was to determine the time for an Amplatzer vascular plug to bring about percutaneous transcatheter occlusion of a pulmonary arteriovenous malformation (PAVM). MATERIALS AND METHODS We retrospectively studied the occlusion times of Amplatzer vascular plugs in the management of 12 PAVMs. We recorded the number, location, type (simple or complex), and diameter and number of feeding arteries of PAVMs; the number and size of devices needed to occlude each PAVM; and the occlusion time for each PAVM. The occlusion time is the time interval from device placement to complete occlusion of the PAVM. Occlusion time was determined by recording the time between acquisition of the first angiographic image after deployment of the device and the angiogram that showed total occlusion of the PAVM. The relevant literature on the subject was reviewed. RESULTS All PAVMs managed were supplied by a single feeding artery. The average diameter of the feeding arteries was 4.8 mm (range, 3.0-11.2 mm). All PAVMs were occluded by deployment of a single Amplatzer vascular plug. Vascular plug sizes ranged from 4 to 16 mm. The mean occlusion time was 3 minutes 20 seconds (range, 1 minute 49 seconds-5 minutes 16 seconds). There were no immediate complications, including air embolism and thromboembolism. CONCLUSION The occlusion time determined in our study and the need to place only one Amplatzer vascular plug in each feeding artery to achieve complete occlusion in most cases suggest that the device is safe for management of PAVM with no increased risk of systemic embolization. The use of the Amplatzer vascular plug for PAVM embolization is a relatively recent development. Long-term follow-up studies are needed to assess recanalization rates, radiation exposure rates, and risk of device migration.

Treatment of Acute Inferior Vena Cava and Iliac Vein Thrombosis With Pharmacomechanical Thrombectomy Using Simultaneously Operating “Kissing” Trellis-8 Thrombolysis Catheters

Purpose To present a new endovascular technique for treating acute large thrombus burden in the iliocaval venous system. Technique This method is demonstrated in a 62-year-old man with end-stage renal disease on hemodialysis who had a nonfunctioning right femoral dialysis catheter that was placed 3 month earlier. After catheter removal, venography demonstrated significant thrombus in the inferior vena cava (IVC) and both iliac veins. The patient was treated successfully using two simultaneously operating Trellis-8 thrombolysis catheters placed side-by-side in the IVC and both iliac veins in a “kissing” configuration. Conclusion This technique was able to effectively debulk acute large thrombus burden in the iliocaval system in a single session and preserve the patients available hemodialysis access. The technique has the potential to minimize morbidity, duration of hospital stay, and overall cost of treatment.

Traumatic Complex Splenic Arteriovenous Fistula Causing Prehepatic Portal Hypertension and Variceal Bleeding The Importance of the Diagnosis for the Endovascular Treatment Approach

We report a case of a 68-year-old female patient presenting with portal hypertension and variceal bleeding in the absence of any liver disease. After performing a computed tomography angiogram, the cause of her condition was identified to be a splenic arteriovenous fistula (SAVF). After confirming the findings with angiography, we opted to treat the condition with coil embolization as an alternative to a more invasive surgical treatment. Coil embolization of the SAVF was performed successfully resulting in the improvement of the patient’s variceal congestion. Our case highlights the importance of identifying SAVF as a potentially curable cause of variceal bleeding in the absence of liver disease. Seeking this diagnosis is of utmost importance since it completely changes the endovascular approach and management of these patients with variceal bleeding. We describe a minimally invasive endovascular technique for treatment of these critically ill patients.

Persistence of pulmonary arteriovenous malformations after successful embolotherapy with Amplatzer vascular plug: long-term results

PURPOSE We aimed to evaluate the frequency of persistence and complication rates of pulmonary arteriovenous malformations (PAVMs) treated with Amplatzer vascular plug (AVP) or Amplatzer vascular plug type 2 (AVP2). METHODS We retrospectively reviewed a total of 22 patients with 54 PAVMs between June 2004 and June 2014. We included 12 patients with 35 PAVMs who received percutaneous embolization using AVP or AVP2 only without the use of any other embolic devices. The mean follow-up was 54±24.3 months (range, 31-97 months). The primary end-points of the study were the efficacy of embolotherapy, the increase in oxygen saturation, and the persistence of PAVM on follow-up. Secondary end point was the incidence of complications. RESULTS The study included 10 female and two male patients with a mean age of 50.2±13.7 years (range, 21-66 years). All PAVMs had a simple angioarchitecture. The technical success of the procedure for PAVM occlusion was 100%. There was a significant increase in the oxygen saturation following embolotherapy (P < 0.0001). Follow-up computed tomography angiography revealed successful treatment in 34 PAVMs (97%) and failed treatment in one PAVM (3%). Twenty-three aneurysmal sacs (67%) showed complete disappearance. The failed treatment was due to persistence of PAVM caused by subsequent development of systemic reperfusion, which did not require further intervention. There were two minor complications but no major complications were encountered. CONCLUSION Embolotherapy of PAVMs using AVP or AVP2 devices is safe and effective, with high technical success rate, low persistence and complication rates, and with excellent long-term results.

Endovascular treatment of acute portal vein thrombosis using ultrasound-accelerated catheter-directed thrombolysis.

We report a case of extensive acute portal vein thrombosis (PVT) presenting with severe diffuse abdominal pain and impending small bowel infarction. The patient was successfully treated with ultrasound-accelerated catheter-directed thrombolysis (EKOS endowave system; Covidien, Mansfield, Massachusetts), which resulted in prompt recanalization of his portal vein (PV) and its tributaries. The patient eventually had ischemic stricture that necessitated bowel resection. However, we believe that our technique was successful in rapidly restoring the patency of the PV and its tributaries, and therefore, avoiding a life-threatening complication of more extensive bowel infarction. To our knowledge, the use of ultrasound-accelerated thrombolysis in treatment of PVT has not been previously described in the literature.

Guide wire entrapment in a vena cava filter: techniques for dislodgement.

Entrapment of a central venous catheter (CVC) guide wire in an inferior vena cava (IVC) filter is a rare, but reported complication during CVC placement. With the increasing use of IVC filters, this number will most likely continue to grow. The consequences of this complication can be serious, as continued traction upon the guide wire may result in filter dislodgement and migration, filter fracture, or injury to the IVC. In this article, we review the various preferred techniques reported in the literature for removal of the entrapped guide wire in particular situations, along with their indications, advantages, and disadvantages. We present simple useful recommendations to prevent this complication.

Unusual appearance and presentation of supratentorial subependymoma in an adult patient.

We report a case of a large, heterogeneously enhancing, pathologically proven, supratentorial subependymoma in a 31-year-old male patient presenting with headache, nausea and vomiting as well as gait disturbances. Although most supratentorial subependymomas have distinctive MR features, our case demonstrated imaging findings that made it indistinguishable from other more aggressive malignant supratentorial intraventricular lesions. It is of paramount importance to consider supratentorial subependymomas in the differential diagnosis of supratentorial lesions, even if their radiological features were atypical.

Endovascular treatment of pancreatic allograft transplant arteriovenous fistula using amplatzer vascular plug 2.

We report a case of simultaneous pancreas–kidney transplant, referred to us with an arteriovenous fistula (AVF) in the transplanted pancreas. The AVF was manifested by compromised functions of the transplanted pancreas. The patient was successfully treated with percutaneous transcatheter embolotherapy using Amplatzer Vascular Plug 2 (St. Jude Medical, Plymouth, MA), after the adequacy of the pancreatic transplant perfusion was ensured to avoid the risk of postembolization pancreatic infarction. There were no complications related to the procedure and the patient pancreatic functions and clinical status returned to baseline. Our case highlights a rare vascular complication related to pancreatic transplant that was managed by minimally invasive endovascular treatment. To our knowledge, the technique used in treatment of this case was not previously described in literature.

Endovascular management of nonvariceal upper gastrointestinal hemorrhage.

Upper gastrointestinal bleeding (UGIB) remains a frequent presentation in the emergency department. There are several causes of UGIB, which can be generally classified into variceal and nonvariceal bleeding. Although most cases of nonvariceal UGIB spontaneously resolve or respond to medical management and/or endoscopic treatment, transcatheter arterial embolization (TAE) remains an important available tool in the emergency evaluation and management of nonvariceal UGIB. In this article, we will discuss the current strategies for rendering a specific diagnosis of nonvariceal UGIB, and we will focus on the various TAE techniques for its management. We will also provide an algorithm for the diagnostic work-up of these patients. The majority of patients with nonvariceal UGIB that is refractory to endoscopic treatment is successfully treated with minimally invasive TAE and can avoid undergoing surgery.

Entrapment of Guide Wire in an Inferior Vena Cava Filter: A Technique for Removal

Entrapment of a central venous catheter (CVC) guide wire in an inferior vena cava (IVC) filter is a rare, but reported complication during CVC placement. With the increasing use of vena cava filters (VCFs), this number will most likely continue to grow. The consequences of this complication can be serious, as continued traction upon the guide wire may result in filter dislodgement and migration, filter fracture, or injury to the IVC. We describe a case in which a J-tipped guide wire introduced through a left subclavian access without fluoroscopic guidance during CVC placement was entrapped at the apex of an IVC filter. We describe a technique that we used successfully in removing the entrapped wire through the left subclavian access site. We also present simple useful recommendations to prevent this complication.