Thomas G. Vrachliotis

Covered Stents to Treat Partial Recanalization of Onyx-Occluded Giant Intracavernous Carotid Aneurysm

Purpose: To present the application of a covered stent for the management of a left internal carotid artery (ICA) aneurysm that had recanalized following embolization with Onyx. Case Report: A 54-year-old man had a giant intracavernous aneurysm of the left ICA successfully occluded with Onyx. Recurrence of symptoms 5 months later prompted control angiography, which showed partial recanalization of the aneurysm. The aneurysm neck was successfully sealed by placing 2 polytetrafluoroethylene-covered stents across it. Control angiography performed at 12 months after stent placement showed no stenosis or signs of recanalization of the aneurysm. Conclusions: Recanalization of giant intracavernous carotid aneurysms post-Onyx treatment may be safely treated with placement of covered stents across the aneurysm neck.

Percutaneous management of extensive clot trapped in a temporary vena cava filter.

Purpose: To present percutaneous management of extensive clot trapped in a temporary inferior vena cava (IVC) filter. Case Report: A 20-year-old man with a large sacral tumor and left external iliac vein thrombosis had a wire-mounted Günther temporary filter (GTF) prophylactically placed in the infrarenal IVC prior to tumor resection. The 7-day postsurgical venogram prior to filter removal showed extensive clot trapped by the filter, as well as interval cephalic migration, with the filter tip now at the level of the renal veins. A Günther Tulip MReye (GTM) filter was deployed but not released above the renal veins to prevent clot migration during caudal withdrawal of the wire-mounted GTF. After creating enough space in the infrarenal IVC, the GTM was repositioned and fully released with its apex now below the renal veins. The GTF was then uneventfully removed. There was no clinical evidence for significant pulmonary embolism 12 months after placement. Conclusions: Cephalic migration of a clotted temporary IVC filter can be managed with intraprocedural protection against pulmonary embolism by first deploying a Günther Tulip filter above the renal veins, with subsequent advancement below the renal veins before temporary filter removal.

CT demonstration of a rapidly growing transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) is the most common urothelial malignancy. We present a case of an exceptionally aggressive TCC involving the renal pelvis and ureter. To our knowledge, an upper tract TCC of such rapid growth has not been reported.

Re: Internal mammary artery pseudoaneurysm complicating central venous line placement: treatment with percutaneous thrombin injection.

We report a case of a proximal right internal mammary artery (RIMA) pseudoaneurysm that was successfully treated with percutaneous injection of thrombin. A 52-year-old woman with a long history of recurrent nonHodgkin’s lymphoma and renal failure had a right subclavian 8 Fr triple-lumen central line placed at the bedside without imaging guidance. The patient had a platelet count of 56,000 but otherwise had a normal coagulation profile (PT: 12.7 sec, PTT: 25.5 sec, INR: 1.1). Line placement was complicated by a mediastinal hematoma confirmed by CT scan. Two weeks after the line had been removed for dysfunction, progressive right chest, neck and face pain prompted a follow-up CT examination that showed interval decrease in the size of the hematoma. However, a new intensely enhancing structure measuring 1.3 1.4 cm between the RIMA and the right brachiocephalic vein was noted, suggestive of a pseudoaneurysm (Figs. 1, 2). Due to the symptomatic nature of the lesion we elected to proceed with arteriography and possible intervention. As an out-patient procedure, the RIMA was catheterized with a 4 Fr headhunter catheter via a right common femoral artery approach. An arteriogram showed contrast filling a pseudoaneurysm (Fig. 3A) arising from the proximal RIMA. Subsequently the catheter was advanced beyond the origin of the pseudoaneurysm with blood being easily aspirated at all times. As CT had shown a small bone-free window (for needle access to the pseudoaneurysm) with a short distance between the skin and pseudoaneurysm, a 19 G needle connected to extension tubing was advanced under fluoroscopy to the body of the pseudoaneurysm, which remained partially opacified after intraarterial contrast injection. Smaller needles did not have enough stiffness to allow passage. Ultrasound (US) guidance was not possible as there was no acoustic window to visualize the pseudoaneurysm. Aspiration of blood, followed by a 3-ml hand injection of contrast, confirmed intraluminal positioning of the needle tip (Fig. 3B). Through the 19 G access needle, 1500 units of topical bovine thrombin (Thrombin-JMI, Jones Medical Industries, St. Louis, MO, USA) diluted in 2 ml of normal saline, were injected into the pseudoaneurysm until flow return from the needle ceased completely. Repeat angiogram confirmed complete occlusion of the pseudoaneurysm, though occlusion of RIMA branches and non-occlusive distal RIMA thrombosis was also demonstrated (Fig. 4). This non-target embolization did not receive specific treatment and had no clinical consequences. The patient reported relief from chest, neck and face pain within 24 hr and has no recurrent symptoms at 4 months follow-up. The use of direct US-guided thrombin injection into iatrogenic pseudoaneurysms was first described by Liau et al. [1] as an alternative to direct US-guided compression of pseudoaneurysms. The procedure is quick, well tolerated, without need for conscious sedation or analgesia and is rapidly and definitively effective even in cases of failed US-guided compression [2]. Thrombin injection for treatment of pseudoaneurysms was initially suggested for treatment of visceral and extremity pseudoaneurysms in 1986 [3]. Internal mammary artery (IMA) pseudoaneurysms are very rare and have been described as complications after median sternotomy or after use of the IMA as a bypass graft [4]. Despite the close proximity of the right subclavian vein to the right internal mammary artery, and despite the high frequency of central venous line placement, IMA pseudoaneurysm after line placement appears to be extremely rare. Described treatment options for IMA pseudoaneurysms include surgical excision and ligation requiring general anesthesia and potential sternotomy [4]. Percutaneous treatment was preferred in our case in an attempt to avoid surgery and its associated co-morbidities.

Infections after endovascular coil embolization.

Dick and colleagues have to be complimented for sharing with the medical community their valuable experience with aortitis following side branch coil embolization prior to endovascular aneurysm repair (EVAR). Only 7 case reports of infectious complications related to endovascular coil embolization in various anatomical regions have been reported, as published in a recent review article. These 2 new cases now add to the relevant literature. In the patients reported by Dick et al., prolonged procedure time, as well as insufficient skin disinfection, might have contributed to these serious infections, since the infectious agents described were microorganisms from the regular skin flora. Since the introduction of EVAR, management of endoleaks with side branch coil embolization has been advocated. Furthermore, thousands of patients worldwide have received and will continue receiving some form of coil embolization treatment. The introduction of a coil, aside from its therapeutic implications, is no less than the intravascular deposition of foreign material. Therefore, strict aseptic conditions must be applied during its introduction. In a case report by Eliason et al., coil embolization to treat a type I endoleak after EVAR was undertaken in the interventional radiology suite, with apparent satisfactory results. However, 2 weeks after embolization, abdominal computed tomography and an indium scan revealed an infected endovascular graft. The patient underwent graft and coil excision with autologous vein reconstruction. The authors stated that this experience of coil-induced infection caused them to consider performing this type of secondary intervention in an operating room environment. In cases of EVAR performed in the operating theater, aseptic conditions should exist by default. However, adjunct procedures, such as coil embolization of endoleak-prone arteries prior to EVAR or treatment of endoleaks after stent-graft repair, might be technically difficult to perform outside the interventional radiology suite due to equipment limitations in the operating room. This comes down to the added expense of enforcing a strict aseptic environment in the interventional radiology suite versus adding necessary imaging equipment to the operating room. It is possible that several more unreported cases exist worldwide that have not gone beyond internal reports in educational meetings or are unpublished autopsy findings. In many instances, it is likely that such infectious complications were simply regarded and treated as part of the patients’ medical condition. For the aforementioned reasons, it is possible that an underreporting of infections after endovascular coil embolization exists, in our opinion.

Impact of Unilateral Common Iliac Vein Occlusion on Trapping Efficacy of the Greenfield Filter: An in Vitro Study☆

RATIONALE AND OBJECTIVES The purpose of this study was to assess the effect of unilateral common iliac vein occlusion on the capturing efficacy of the Greenfield filter in vitro. MATERIALS AND METHODS A stainless steel over-the-wire Greenfield filter was placed in the Silastic inferior vena cava module of a pulsatile circuit. Three 30-mm blood clots in sets of five were injected through the modules right iliac limb with the circuit in four experimental conditions: vertical position, both iliac limbs patent (VP); vertical position, left iliac limb occluded (VOC); horizontal position, both iliac limbs patent (HP); and horizontal position, left iliac limb occluded (HOC). Each experiment was repeated 15 times, resulting in 75 clots per condition and a total of 300 clot introductions. RESULTS Clot trapping efficacy was 36 of 75 (48%) for VP, 41 of 75 (55%) for VOC, 32 of 75 (43%) for HP, and 26 of 75 (35%) for HOC. Cross comparisons of the four conditions revealed a marginally significant difference (P = .0138 with a corrected test-wise alpha = .0125) only between horizontal and vertical positions with unilateral common iliac limb occlusion. CONCLUSION Unilateral common iliac vein occlusion decreases the capturing efficacy of the Greenfield filter in the horizontal position in vitro. In patients with unilateral common iliac vein occlusion, use of inferior vena cava filters with higher capturing efficacy may be considered.

Impact of Graft Material Configuration on Stent-Graft Endoleak In Vitro

PURPOSE To assess the effect of different attachment patterns between graft materials and stents on type I endoleak. MATERIALS AND METHODS Nitinol stents were covered with a coating of Tegaderm in either a straight-edged pattern across the stent cells or a contoured zigzag pattern conforming to the stent skeletons honeycomb-shaped cells. The stent-grafts were deployed in an ex vivo circuit across a gap of tubing to simulate an aneurysm cavity. Fluid leaking from the gap for more than 30 minutes was recorded as endoleak. Two contoured attachment patterns (short and long necks) and four straight-edged patterns with necks of varying length were tested. Each experiment was repeated 15 times. RESULTS The length of the aneurysm neck covered by the graft material was inversely related to the rate of endoleak. The zigzag pattern of graft attachment demonstrated significantly less endoleak than the straight-edged pattern in the setting of a short aneurysm neck (0.25 mL vs 47.3 mL). CONCLUSION Adopting the contoured (zigzag) attachment of graft material to stents minimizes endoleak in vitro, particularly in the setting of a short aneurysm neck.

Aberrant Supply of the Common Penile Artery from an Inferior Epigastric/External Pudendal Artery Trunk: Radiological and Urological Implications: A Case Report

In cases of arteriogenic impotence, penile angiography is often performed before penile revascularization. Evaluation of the inferior epigastric arteries is critical for preoperative planning, for use of the dominant vessel is preferred. Performance of penile angiography requires knowledge of the extensive variations of the penile arterial system. This case report describes an anatomical variation of both the inferior epigastric artery and the penile arteries. Failure to recognize this variation could have resulted in a failed penile revascularization if surgery had been performed.