Shaheen Dixon

Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization.

A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

The role of interventional radiology and imaging in pancreatic islet cell transplantation

Pancreatic islet cell transplantation (PICT) is a novel treatment for patients with insulin-dependent diabetes who have inadequate glycaemic control or hypoglycaemic unawareness, and who suffer from the microvascular/macrovascular complications of diabetes despite aggressive medical management. Islet transplantation primarily aims to improve the quality of life for type 1 diabetic patients by achieving insulin independence, preventing hypoglycaemic episodes, and reversing hypoglycaemic unawareness. The islet cells for transplantation are extracted and purified from the pancreas of brain-stem dead, heart-beating donors. They are infused into the recipients portal vein, where they engraft into the liver to release insulin in order to restore euglycaemia. Initial strategies using surgical access to the portal vein have been superseded by percutaneous access using interventional radiology techniques, which are relatively straightforward to perform. It is important to be vigilant during the procedure in order to prevent major complications, such as haemorrhage, which can be potentially life-threatening. In this article we review the history of islet cell transplantation, present an illustrated review of our experience with islet cell transplantation by describing the role of imaging and interventional radiology, and discuss current research into imaging techniques for monitoring graft function.

Corona Mortis Artery as a Cause of a Type II Endoleak in an Internal Artery Aneurysm

Editor: The present communication reports a rare cause of a type II endoleak in a patient treated for an isolated internal iliac artery (IIA) aneurysm. A 70-year-old patient underwent open surgical aortobiiliac graft placement in 1995. On follow-up computed tomographic (CT) angiography in 2005, the patient was found to have a type I right IIA aneurysm 94 91 mm in size, with its origin commencing at the bifurcation of the IIA (neck diameter measuring 8 mm) to involve the posterior and anterior divisions. This was embolized with an AMPLATZER Vascular Plug (AGA Medical, Golden Valley, Minnesota) and coils within the distal IIA and its branches, followed by an 18-mm 55-mm Zenith stent-graft (Cook, Cork, Ireland) eployed in the right common iliac artery, across the orifice f the IIA. A 2-year follow-up CT angiogram demonstrated persistent type II endoleak into the right IIA aneurysm, ith an increase in the aneurysm sac size from 94 91 mm o 103 97 mm. Branches of the inferior epigastric artery ppeared to perfuse the aneurysm (Fig 1). The patient ubsequently underwent embolization of the aneurysm sac. Right common femoral access was obtained. With a -F SOS Omni catheter (Boston Scientific, Nanterre, rance) within the right common iliac artery, angiography emonstrated reversed flow into the obturator artery (OA)

Prospective study evaluating technical and clinical outcomes from the use of low profile angioplasty (LOPA) systems.

AIM To compare the success and complication associated with 4 and 5 F access systems prospectively in the treatment of infra-inguinal vascular disease. MATERIALS AND METHODS One hundred and twenty consecutive patients were treated for lower limb vascular disease via a 4 F (n = 60) or 5 F (n = 60) access sheath over a 12 month period. All common femoral arteries were punctured in an antegrade direction with ultrasound guidance. Seven minutes of manual compression was applied and the groin assessed with ultrasound to document complications. Repeated manual compression was applied until haemostasis was achieved in all cases. Time to haemostasis, equipment used, patient biochemical data, and demographics were recorded. Patients were followed-up at a mean of 12 weeks post-procedure. RESULTS Antegrade access and sheath insertion was achieved in all cases. The technical success of the procedure was 56/60 (93%) cases using 4 F access and 57 (95%) cases using 5 F access. The time to haemostasis was reduced to a mean of 8.2 min (range 7-12 min) with a 4 F system compared to a mean of 12 min (range 7-30 minutes) with a 5 F system (p = 0.045). Overall there were 12 complications (10%; 11 <2 cm haematomas and one pseudoaneurysm) noted on ultrasound post-haemostasis, although there was no statistically significance difference between the two groups. Hypertension and renal dysfunction were associated with complications (p < 0.05). A 4 F system used an additional average of 5.1 (range 3-8) wires and catheters compared to an additional average of 3.5 (range 2-6) wires and catheters when using a 5 F system (p = 0.002). A 4 F technique cost three-times that of a 5 F technique. CONCLUSION Four and 5 F access sheaths allow safe and successful infra-inguinal angioplasty with a low complication rate. Hypertensive patients and those with impaired renal function are at increased risk of complications. There are increasing costs using a 4 F system offset by a decrease in time to haemostasis following manual compression but no reduction in complication rate.

Letter Reply Re: “Endoscopy-Guided Empiric Arterial Embolization for Angiographically Negative Upper Gastrointestinal Bleeding: Use it Without Fear!”

To the Editor, We thank the author’s constructive comments and appreciate the opportunity to respond to the comments about our article [1]. We agree with the comment that the rate of active bleeding at angiography in our study was low at 32.5 % comparable to some studies [2, 3]. However, our figure is similar to a study by Padia et al. [4] where approximately 33% of patients showed active contrast extravasation during angiography. In our study, a majority of the patients who underwent empiric embolization had prior endoscopy (82 %, 14/17) with either refractory or failed attempted endoscopic treatment. This attempt to achieve hemostasis combined with the known intermittent nature of upper gastrointestinal bleeding (UGIB) may have been contributing factors to the low contrast extravasation rates observed. The use of provocative angiography was first described in 1982 [5]. In our institution, we do not routinely use vasodilator and anticoagulants to induce bleeding. This may have increased the number of positive cases; however, in the few cases for which we have used them, we did not find them particularly useful. There is increasing evidence for using empiric GDA embolization [1–4, 6]. The literature has demonstrated that provocative angiography has been useful and safe in lower gastrointestinal hemorrhage [6], but there is little evidence for its use in UGIB. In patients who are already compromised, there is still a theoretical risk of provocative-related hemorrhage, thereby making them further unstable. We agree that empiric embolization of the suspected culprit artery is important and the role of a multidisciplinary team is fundamental. As we adopt an increasingly aggressive approach to empiric embolization, the need for provocative angiography also will decrease.

Early endovascular salvage of a bovine pericardial superior vena cava graft.

iliac artery (EIA) and not the IIA, prior knowledge of a CM-related bleed helps direct initial angiography toward the EIA territory rather than the IIA territory, the latter being the traditional approach for pelvic embolization in trauma (2). Identification and embolization of the bleeding vessel are expedited, saving crucial time in the context of severe trauma. From our case, interrogation of the EIA territory in the presence of lower pelvic fractures (acetabulum and rami) would seem to be mandatory, regardless of the findings of IIA angiography. This finding is particularly important given that CM can be seen in 30% of patients (1). Further studies using newer “on-table” angiographic techniques such as cone-beam CT or hybrid CT angiography for detection of CM in trauma would be relevant.