Susan Anthony

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.

Embolization of the Internal Iliac Artery with Glubran 2 Acrylic Glue: Initial Experience with an Adjunctive Outflow Occlusive Agent

The authors describe their initial experience with the adjunctive use of Glubran 2, a cyanoacrylate glue, in the embolization of the internal iliac artery (IIA). Glubran 2 was used in five patients as an adjunct to traditional techniques in the repair of isolated IIA aneurysms and to prevent retrograde perfusion of the aneurysm sac in the endovascular repair of aortoiliac aneurysms.

Liquid embolization of the gastroduodenal artery before selective internal radiotherapy (SIRT)

Selective internal radiotherapy (SIRT) is a valuable technique in the palliative treatment of primary and secondary liver tumours. Before yttrium-90 microsphere embolization of hepatic tumours, the gastroduodenal artery (GDA) has to be embolized to prevent the migration of microspheres and the subsequent formation of non-healing ulcers of the upper gastrointestinal tract. A meticulous angiographic technique is required to prevent complications during SIRT as emphasized in best practice guidelines.1 A safe and effective way of performing this is with standard pushable or fibred interlock detachable coils (IDC). Fibred IDCs have been shown to be superior to pushable coils.2 Dudeck et al.2 found that a combination of embolic devices can be required and deployment can be difficult if the guide catheter is sharply angulated in a tortuous GDA. The present authors hypothesized that in tortuous anatomy a liquid embolic agent could be successful in the embolization of the GDA. We present a case of GDA embolization with the liquid embolic agent Onyx (ethylene vinyl alcohol (EVOH) co-polymer dissolved in dimethyl sulphoxide (DMSO) with suspended micronized tantalum powder) and discuss the advantages and disadvantages of using such an agent.

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)

Reply to the Article Entitled “Emergency Renal Ablation for Life-Threatening Hemorrhage from Multiple Capsular Branches During Renal Artery Stenting” by Aytekin et al.

We had a case of life-threatening renal hemorrhage after renal artery stenting, as described by Aytekin and colleagues [1]. In our case. we managed to control the bleeding with microcoils and renal preservation rather than renal ablation. We discuss our case to further establish renal parenchymal hemorrhage after renal artery stenting as a distinct clinical entity and also to highlight a different management strategy. An 82-year-old man underwent right renal artery stenting for atherosclerotic renal artery origin disease before endovascular abdominal aortic aneurysm repair (EVAR). The patient had impaired renal function (creatinine 190–250 lmol/l) and an atrophied left kidney. The right kidney had a dual blood supply, one by the stenotic right main renal artery and the other by a lower-lobe accessory renal artery. Because of the anatomy of the abdominal aortic aneurysm neck, we planned to cover the right lower pole accessory artery with the stent graft to obtain a good seal on the proximal neck of the stent graft. In view of the atrophic left kidney, we chose to electively stent the right renal artery 1 week before the planned EVAR to optimize the right renal blood flow to what was functionally a solitary right kidney. A 6 9 24-mm stent (Cordis Europa, Roden, The Netherlands) was placed across the right renal artery origin stenosis and dilated to 7 mm (Wanda, Boston Scientific, Galway, Ireland) with good angiographic result. The patient was then admitted to our day case unit for recovery. Within 1 h of the procedure, the patient developed severe right flank pain, and his systolic pressure dropped to 90 mm Hg from a baseline of 160 mm Hg. An ultrasound showed a large perinephric collection. He was taken back to the interventional suite. A right renal angiogram showed a blush of contrast from an upper pole cortical vessel, which was embolized with microcoils (Fig. 1). One hour later, the patients’ blood pressure dropped again, and he complained of increasing right flank pain. A further computed tomographic angiogram showed active bleeding from a right lower pole vessel, and again, the patient was returned to the interventional suite. There was a blush of contrast from the lower pole renal cortical arteries. The subsegmental renal artery supply the lower pole segment was further embolized with microcoils (Fig. 2). The patient settled after the second embolization but required temporary dialysis for contrast-induced nephropathy. The renal impairment was probably caused by a combination of a large intravenous contrast load (approximately 300 ml Omnipaque) and a large perirenal hematoma, which compromised renal perfusion. EVAR was performed 2 weeks later. The patient subsequently recovered renal function to baseline preprocedural levels. The multifocal nature of the renal hemorrhage did not correspond to guide wire perforation. We think this is best explained by hemorrhage from multiple capsular branches, as described previously [2, 3]. Reperfusion of the kidney may play a role in the underlying etiology. Our experience demonstrates that selective embolization is an alternative management strategy, particularly in the setting of a functionally solitary kidney. Appropriate intensive care aftercare is important to minimize renal damage from contrast load. V. Shrivastava (&) S. Anthony M. Bratby R. Uberoi Radiology Department, John Radcliffe Hospital, Oxford, UK e-mail: vivshriv@yahoo.com

Primary pulmonary artery sarcoma presenting as right heart failure

Figure 1: (A) Magnetic resonance imaging—primary sarcoma obstructing the pulmonary arteries. (B and C) Computed tomography (CT) reconstructions showing the almost complete obstruction of the bifurcation of pulmonary arteries. (D) CT angio of the reconstruction of the right ventricular outflow, main pulmonary artery and the bifurcation using homograft. (E and F) CT reconstructions of the repair after excision of sarcoma.