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56
R. K. Patel et al.
Fig. 7.3 Post-whipple GI
bleeding from PsA at PHA
bifurcation managed with
detachable coil packing of
sac. (a) CHA angiogram
shows a saccular PsA at
hepatic artery bifurcation; (b)
microcatheter was advanced
into the PsA sac, followed by
sac packing using two 8mm
IDC coils (Boston Scientic);
(d) post-coiling angiogram
shows exclusion of PsA with
patent hepatic artery. Stent
graft placement was not
feasible due to tortuous
anatomy, and parent artery
occlusion was not a choice in
view of hepatic ischemia. PsA
pseudoaneurysm, PHA proper
hepatic artery, CHA common
hepatic artery, IDC interlock
detachable coil
a
c
b
d
most suitable for a saccular aneurysm with a narrow neck.
The narrow neck of the aneurysm prevents the inadvertent
migration of embolic materials into the parent artery. Coils
or liquid embolic agents are most commonly used for this
approach. Precise measurement of three-dimensional aneurysm size and intraprocedural calculation of packing density is essential to ensure adequate coil packing. A tight coil
packing with a density of >24% is required to avoid late
coil compaction or recanalization. Large and wide-neck
aneurysms may need additional neck remodeling techniques [18].
If possible, the sac packing technique should be avoided
for pseudoaneurysms. Due to the lack of the three-layered
arterial wall in pseudoaneurysms, sac packing may lead to
aneurysmal expansion and increase the risk of rupture.
However, when no other option is available, and parent artery
patency is desired, sac packing using detachable coils may
be considered as a salvage measure to control bleeding
(Fig.7.3) [19].
Stent or Balloon-Assisted Coiling [20, 21]
Stent or balloon-assisted coiling is considered in large and
wide-neck aneurysms arising from a non-expandable artery,
and a covered stent cannot be placed. In the stent-assisted
coiling technique, an uncovered stent is placed across the
neck of the aneurysm. The aneurysmal sac is packed with
coils via a microcatheter introduced through the stent mesh.
The stent provides a scaffold that prevents the prolapse of the
coil into the parent artery during coil packing.
In the balloon-assisted technique, after gaining access
into the aneurysmal sac through a microcatheter, a nondetachable balloon is temporarily inated across the neck of
the aneurysm during coil packing or liquid embolic administration. Once the embolic cast is formed within the aneurysm
and the aneurysm is thrombosed, the balloon is deated and
removed; with an end result of exclusion of the aneurysm but
a patent parent artery. In bifurcation aneurysms, technical
modications are required, necessitating the ination of
more than one balloon at a time. These assisted techniques
increase the procedural cost. Furthermore, in the case of
stent-assisted coiling, long-term antiplatelet therapy is often
recommended.
Multi-Layered Flow-Diverting Stents [22]
Flow diverters are most commonly used in treating intracranial aneurysms, especially for large and wide-neck
aneurysms that are otherwise not amenable to standard
endovascular techniques. The ow-diverter modulates the
7 Embolization inInterventional Radiology
57
blood ow away from the aneurysmal sac while maintaining ow through the normal vessels, thereby enhancing
thrombus formation within the aneurysmal sac. Besides
limited clinical experience, their high cost of ow-diverters
makes them less favorable for extracranial aneurysms.
Further, its use in pseudoaneurysms is limited, as thrombosis occurs slowly, and there is a possibility of rupture in the
interim.
7.6.1.2 Parent Artery Occlusion
Sandwich Technique [19–22]
This is one of the most commonly used techniques for embolizing visceral artery aneurysms (VAAs), with a clinical success rate of >90%. The parent artery must be expandable to
use this technique. In this technique, the parent artery is
occluded both proximal and distal to the aneurysmal neck to
avoid retrograde aneurysm lling from the collaterals. The
efferent artery or backdoor is closed rst, followed by the
afferent artery or backdoor (Fig. 7.4). Coil and vascular
plugs are the most commonly used embolic agents for this
approach. However, it precludes repeat transarterial embolization in the future if re-bleeding occurs or bleeding occurs
from an artery distal to the embolized artery.
Only Proximal Inow Embolization [16, 17, 23]
This technique refers to the proximal embolization of the
feeding artery. It is used for end arteries (e.g., renal artery)
and distal lesions in the intraparenchymal vessels (e.g., intraparenchymal distal splenic artery pseudoaneurysm).
Embolization should be performed as selectively as possible
to limit the area of infarct (Fig.7.5).
7.6.1.3 Percutaneous Approach [16, 17, 24, 25]
A percutaneous approach is considered in case of a failed
endovascular approach or an aneurysm that is inaccessible
endovascularly. The aneurysm or pseudoaneurysm must be
accessible under USG or CT guidance. A pseudoaneurysm
should be surrounded by a solid organ or considerable
peripheral thrombus rim to avoid the risk of aneurysmal rupture during the percutaneous approach. The aneurysmal sac
is punctured using a 22G lumbar puncture (LP) or Chiba
needle, keeping the tip away from the aneurysmal neck to
avoid non-target embolization (Fig.7.6). Then, the embolizing agent is slowly administered under guidance until thrombosis of the sac occurs. Thrombin, glue, and occasionally
coils are used as embolic agents. At times, the balloonassisted embolization technique is combined with a percutaneous approach, especially when there is a relatively high
risk of non-target embolization. A balloon is placed across
the neck via an endovascular approach, the aneurysm is
accessed, and the embolic agent is injected via a direct percutaneous approach under CT or USG guidance (Fig.7.7).
Despite a higher risk of complications, certain situations
require glue embolization. The indications include the inability to reach the target site due to unfavorable vascular anatomy, re-lling pseudoaneurysm following coil embolization,
and in patients with coagulopathy when coil or vascular plug
alone may not sufce. The operator must be aware of ow
dynamics and essential vascular anatomy to decide the glue
concentration, amount, and injection rate to avoid non-target
embolization [16, 17]. Newer liquid embolics, such as Onyx,
Squid, and PHIL, provide superior control than glue; hence,
these are favored over glue in critical locations, e.g., neurointervention [15].
a
Fig. 7.4 Sandwich technique for SMA pseudoaneurysm coiling. (a)
DSA shows a saccular PsA (dotted white circle) arising from the proximal right colic artery; (b, c) Embolization was performed using two
microcoils placed across the PsA neck (black arrows b, c), occluding
b
c
both the front and backdoor of PsA (also known as sandwich technique). Post-embolization DSA shows exclusion of PsA with lling of
distal colic branches. SMA=superior mesenteric artery, DSA digital
subtraction angiography, PsA pseudoaneurysm
58
a
R. K. Patel et al.
Fig. 7.5 Post-PCNL renal
artery pseudoaneurysm
treated with coil embolization.
(a) NCCT showing a
perinephric hematoma; (b)
CTA demonstrates a right
renal artery pseudoaneurysm
(black arrow b); (c) right
renal angiogram conrmed a
pseudoaneurysm, arising from
the lower polar artery (black
arrow c), which was super
selectively embolized with a
4mm microcoil; (d)
post-coiling angiogram
reveals no lling of PsA with
the normal arterial ow to the
rest of the right kidney. PCNL
percutaneous
nephrolithotomy, NCCT
non-contrast CT, CTA CT
angiography, PsA
pseudoaneurysm
b
c
d
7.6.2 Tumoral Embolization
cone-beam CT (CBCT) makes tumoral embolization easy. It
provides detailed vascular anatomy and helps target the
Tumoral embolization is used for tumor devascularization
intended to provide palliative in terms of pain reduction,
decrease in tumor size, and control or prevention of hemorrhage. Preoperative embolization is also done in case of
hypervascular tumors (e.g., renal cell carcinoma, renal
angiomyolipoma, juvenile nasopharyngeal angiobroma,
carotid body tumor, and soft tissue hemangioma) to
reduce operative blood loss (Fig.7.8). Commonly used
embolic agents include gelfoam slurry, PVA particles, or
glue/onyx [26, 27]. Chemotherapeutic drugs can be mixed
with a carrier (lipiodol or drug-eluting bead) to perform
intratumoral chemotherapy, called chemoembolization
(e.g., TACE for hepatocellular carcinoma) (Fig. 7.9).
Similarly, radioactive particle-labelled microspheres are
used for intratumoral radiotherapy, known as radioembolization or selective internal radiation therapy (TARE/
SIRT) [28–30].
A pre-procedural CT helps identify relevant vascular
anatomy and feeder vessels, reducing procedural time and
radiation exposure. Whenever available, intraprocedural
appropriate feeder arteries. It also helps in deciding the end
point of embolization [31].
Preoperative embolization of head and neck tumors needs
special mention owing to their locations in the vicinity of
different vital structures, and the presence of multiple important intra-extracranial vascular anastomoses may complicate
the embolization procedure. The transarterial route is routinely used for embolization. However, percutaneous direct
puncture techniques using liquid embolic agents have also
been reported. Selective catheterization of external and internal carotid artery branches is required to delineate the
tumoral feeders adequately. Further, a selective DSA run
may show the important ECA-ICA anastomoses and ocular
supply for which care should be taken during the embolization [26–28].
The commonly used embolic agents for this purpose are
particulate and liquid embolic agents. Particle size should
not be very small (usually <150μm) because smaller particles may lead to non-target penetration into vasa vasorum,
resulting in cranial nerve palsies or entering the intracranial
7 Embolization inInterventional Radiology
59
Fig. 7.6 Percutaneous
USG-guided glue
embolization of uterine artery
pseudoaneurysm following
hysterectomy. (a) USG
Doppler shows a well-dened
pseudoaneurysm at the
vaginal vault with ying-yang
sign within (open white arrow
a); (b, c) axial and coronal
CECT images conrmed the
pseudoaneurysm arising from
left uterine artery stump
(thick yellow arrow c); (d)
under USG guidance,
pseudoaneurysm was
accessed by a 22G Chiba
needle (thin white arrow d)
through percutaneous
puncture and was embolized
using a 30% glue-lipiodol
mixture (open black arrow d).
USG ultrasound, CECT
contrast-enhanced CT
a
c
b
d
circulation, causing focal neurological decits. To maximize
the benets of the embolization procedure, the surgical
resection should be carried out 1–8days after the embolization [26, 32].
7.6.3 AVM Embolization
The embolization of arteriovenous malformation (AVM)
requires obliteration of nidus and venous outow to avoid
recurrence while minimizing non-target embolization. This
can be best achieved by slowing the ow to improve operator
control and intra- or juxtanidal positioning of the catheter.
Nidus is accessed antegradely through arterial, retrogradely
through venous approach, or direct puncture, depending
upon the types of AVM. Further, ow reduction can be
achieved through balloon occlusion or plugging of inow
artery/outow vein using coil, glue, vascular plug, or a combination of these (Fig.7.10). In supercial locations, a blood
pressure cuff or manual compression of veins may sufce for
ow reduction. One must be aware of the risk of non-target
reux of embolic agents into the arterial system while using
complete outow vein occlusion [33].
In AVM with multiple outow veins, procedural modi-
cation such as “cookie cutter technique” may be required for
simultaneous occlusion of multiple venous ow while embolizing the nidus or venous sac through direct percutaneous
injection of liquid embolic agents [34].
In complex high-ow AVM, particularly in the brain, the
“pressure cooker technique (PCT)” is a modication to avoid
reux and enable a relatively forceful and contiguous injection of liquid embolic (most commonly Onyx) for complete
embolization. The PCT consists of creating a plug of coils
and glue between the tip and the detachment zone of a previously placed DMSO-compatible microcatheter. Although
less common, this PCT may also be used through the venous
approach [35, 36].
7.6.4 Embolization inTrauma [37, 38]
Organ with dual blood supply or extensive collateral circulation (e.g., liver, Upper GI tract) tolerates a relatively larger
area of embolization. Vessels in patients with trauma tend to
spasm frequently, and hence, vascular spasm must be considered while planning for embolization. In case of massive
bleeding with multiple areas of contrast, extravasation necessitates non-selective embolization using gelfoam (e.g., multiple sites of bleeding from pelvic vessels or liver). When the
patient is relatively stable, superselective embolization
60
R. K. Patel et al.
a
c
d
b
e
Fig. 7.7 Balloon-assisted percutaneous thrombin injection for a large
femoral artery pseudoaneurysm. (a) USG shows a large PsA with a jet
of ow arising from SFA; (b) DSA conrmed the USG ndings, showing a large PsA (open white arrow b); (c) a 6-mm balloon (yellow arrow
c) was inated across the neck of the PsA, followed by percutaneous
should be considered to prevent non-target tissue ischemia or
necrosis. Of note, end-arterial organ embolization must be
performed superselectively to minimize non-target tissue
ischemia (e.g., kidney).
7.6.5 Special Scenario
7.6.5.1 Provocative Angiography
In some cases, provocative angiography may improve the
diagnostic yield when invasive angiography remains negative despite a very high degree of clinical suspicion (e.g.,
ongoing GI bleeding with negative angiogram). To identify
the site of bleeding, bleeding is induced using systemic heparinization and selective injection of a vasodilator with a
thrombolytic. However, the safety of this approach is controversial and should only be considered in patients with
repeated negative angiographies [39].
thrombin injection under USG guidance (open white arrow d), resulted
in thrombus formation (open red arrow d) without any distal spillage of
thrombin; (e) post-thrombin injection DSA reveals exclusion of PsA.
PsA pseudoaneurysm, S FA supercial femoral artery, DSA digital subtraction angiography
Despite active bleeding, the arterial injury site may be
obscured due to the tamponade effect by an adjacent indwelling catheter (e.g., hemobilia from arterio-biliary stula after
PTBD placement). In such cases, a repeat catheter angiography following removal of the catheter (over a guidewire) can
unmask the arterial injury site, and then embolization can be
performed [40].
7.6.5.2 Lower GI Bleeding
While the upper GI tract has extensive arterial collateralization, the GI tract beyond the ligament of Trietz has poor collateralization. This raises a concern for bowel ischemia if
embolization is not very accurate at the bleeding site with the
occurrence of non-target embolization [41]. The goal is to
embolize superselectively at the level of the vasa recta and
avoid the marginal artery. Detachable coils are most commonly used. Particles and glue are less preferred due to their
increased risk of bowel infarction [42, 43].
7 Embolization inInterventional Radiology
61
Fig. 7.8 Pre-operative JNA
embolization. (a) CTA
showing a right-sided
hypervascular mass in the
nasopharynx; (b, c) DSA
images show multiple feeders
from right ECA (open black
arrow); (d) post-PVA
(350–500 microns)
embolization DSA shows
disappearance of tumoral
blush. JNA juvenile
nasopharyngeal angiobroma,
ECA external carotid artery,
DSA digital subtraction
angiography
a
c
b
d
7.6.5.3 Hepatic Artery Aneurysm
To minimize the risk of hepatic ischemia, portal vein patency
should be conrmed before extensive intrahepatic arterial
embolization or proper hepatic artery embolization is
planned. A common hepatic artery aneurysm or pseudoaneurysm is best treated using a stent graft or stent/balloonassisted coiling [17]. Of note, the hepatic artery is the only
source of blood supply to the biliary tree in the transplanted
liver. Hence, an artery preservation strategy must be adopted
to avoid the risk of biliary necrosis and abscess formation.
Stent grafting, or stent/balloon-assisted aneurysmal coiling,
is the treatment of choice for aneurysms arising from the
common hepatic artery [16].
7.6.5.4 Renal Artery Aneurysm (RAA)
The renal artery is an end artery, and proximal embolization
leads to distal tissue ischemia. Therefore, the embolization
strategy in renal vasculature aims to preserve parent artery
ow with the exclusion of pathology or at least to embolize
as superselectively as possible to limit the extent of distal
tissue ischemia. Aneurysm in the main renal artery necessi-
tates stent graft placement with a landing zone of 15mm,
while aneurysm arising from extra-renal proximal arterial
bifurcation is treated by stent or coil-assisted coil or onyx
embolization. RAA from the distal renal artery is managed
with just-aneurysmal proximal coil embolization [21, 23].
7.6.5.5 Percutaneous Transhepatic or Transplenic
Access forEmbolization
Portal vein embolization requires either percutaneous transhepatic or transplenic access. Variceal or large portosystemic shunt embolization may also require a transhepatic or
transplenic route. An intraparenchymal vein is punctured
using a 21 or 22G Chiba needle under USG guidance, followed by the insertion of a vascular sheath. After embolization is completed, the percutaneous access tract is embolized
using a combination of coil and glue to avoid the risk of
intraperitoneal hemorrhage (Fig.7.11) [44, 45].
62
R. K. Patel et al.
Fig. 7.9 TACE for HCC. (a)
Arterial phase CT reveals a
well-dened hypervascular
HCC; (b) hepatic artery
angiogram shows tumoral
blush (yellow arrow b).
Initially, a mixture of
epirubicin and lipiodol was
injected, followed by
embolization of feeder
arteries by gelfoam slurry. (c)
Post-TACE angiogram shows
disappearance of tumor blush;
(d) follow-up CT after 1day
demonstrates lipiodol cast
(black arrow d) within the
HCC. TACE transarterial
chemoembolization, HCC
hepatocellular carcinoma
a
c
b
d
a
c
d
b
e
Fig. 7.10 Uterine AVM embolization using balloon-occluded arterial
inow control. (a) Axial CTA and (b) VRT images show large uterine
AVM (red arrows), supplied by bilateral uterine arteries with early
draining right iliac vein; (c) right internal iliac DSA demonstrates the
AVM (open red arrow c). Due to very high ow, the arterial inow was
initially slowed using an 8-mm balloon inated in the right internal iliac
artery (white arrow b), followed by embolization of nidus through a
microcatheter (thin black arrow d) using a 40% glue-lipiodol mixture
(open black arrows in d showing glue cast). CTA CT angiography, AVM
arteriovenous malformation, DSA digital subtraction angiography
7 Embolization inInterventional Radiology
63
Fig. 7.11 Transplenic gastric
variceal embolization for
bleeding in a patient with
sinistral portal HTN. (a)
Coronal MIP CT image shows
multiple varices along the
gastric wall (white arrows a)
with thrombosed splenic vein;
(b) splenic venogram through
a transplenic access reveals
multiple varices (black arrow
b), supplied by short gastric
vein (yellow arrow b). Glue
embolization was done. (c)
Post-embolization venogram
showed obliteration of the
varices with glue case (open
white arrows c, d). In the end,
transplenic route was
embolized using 50%
glue-lipiodol solution (red
arrow d)
a
c
b
d
7.7 Newer Embolizations
7.7.1 Genicular Artery Embolization
Osteoarthritis of the knee is the leading cause of chronic pain
and disability in older people. Traditionally, OA knee is managed stepwise, ranging from conservative management and
medical therapy for mild to moderate OA knee to arthroplasty for the severe grade of disease. Angiogenesis plays a
pivotal role in its pathogenesis by fueling chronic inammation and perpetuating degenerative joint changes [46]. In a
minimally invasive manner, genicular artery embolization
(GAE) selectively embolizes the geniculate branches corresponding to the site of pain, inhibiting the vicious cycle of
inammation and pain generation [46, 47].
GAE improves joint pain, function, and quality of life
with a durable response ranging from 6 to 24 months.
Importantly, GAE is best served as an effective adjunct therapy that can reduce the use of other conservative therapies
(NSAIDs, opioids, and joint injections) and delay or prevent
surgical intervention [46–48].
A clear understanding of the knee’s structural and genicular artery anatomy is crucial to perform embolization safely
and effectively. After vascular access, a superselective angiographic run of each genicular artery is taken using a microcatheter to identify the synovial blush, and an embolic agent
is delivered until the synovial blush has disappeared. As the
medial compartment is commonly affected in OA knee,
branches of medial and descending genicular arteries are the
most common embolization targets. Usually, 2–3 vessels
with pathological synovial blush per knee are embolized,
leaving some arteries to preserve blood supply to the joint
capsule [47]. GAE has a >80% technical success rate. GAE
is also used to treat recurrent hemarthrosis [47, 49, 50].
Permanent particulate agents are used as embolic material. Different embolic agents used for GAE are Embozene
microspheres (75–100 μm), Embospheres (Merit medical
systems; 100–300μm), and PVA (10–70μm). Imipenem and
cilastatin have also been used for successful embolization
[46]. To minimize non-target embolization to cutaneous
branches, an ice pack around the joint should be placed to
cause vasospasm and prevent the migration of embolic materials to the skin [50].
7.7.2 Other Transarterial Embolization (TAE)
forChronic Musculoskeletal Pain
The usage of therapeutic transarterial embolization (TAE)
has also been extended to other pathologies attributing to
chronic musculoskeletal pain, such as adhesive capsulitis in
the shoulder joint, shoulder tendinopathy, lateral epicondylitis in the elbow, elbow tendinopathy, trapezius myalgia,
enthesopathy, and plantar fasciitis. TAE is usually used as an
adjunct therapy, particularly in patients with pain refractory
to medical treatment [51–55]. The concept behind TAE is the
64
R. K. Patel et al.
same as that of GAE, i.e., reducing the vascular blush due to
neoangiogenesis, which slows down the vicious cycles of
chronic inammation and pain generation. Adequate vascular and structural anatomy knowledge is paramount for successful embolization without complications [51, 54].
7.7.3 Bariatric Artery Embolization (BAE)
forObese Patients
Obesity is a major public health issue, predisposing to multiple diseases, such as type 2 diabetes mellitus, cardiovascular disease, and cancer. Benets from rst-line therapies,
including nutritional modication, exercise, and pharmacotherapy, are often temporary and non-sustainable. Despite
the most effective method, bariatric surgery is limited by its
invasive nature, high price, and signicant rate of postoperative morbidity and mortality. Recently, the endovascular technique of bariatric artery embolization (BAE) has
been studied as an obesity and overweight treatment with
promising results [56, 57].
It is worth mentioning that BAE is not a replacement for
bariatric surgery but a complementary to facilitate weight
loss with lifestyle modication. Thus, BAE could serve as a
bridge or a complementary therapy to bariatric surgery [57].
Extrapolating from the hormonal mechanism of weight
loss in bariatric surgery, BAE aims to reduce the production
of Grehelin, an orexigenic hormone most commonly produced in the gastric fundus. There is no universal recommendation regarding the ideal candidate for BAE.However, two
of the largest trials, i.e., GET-LEAN and BEAT obesity trial,
included patients of BMI>40kg/m2 for BAE [57–59].
In BAE, selective embolization of the gastric fundus is
performed using particulate embolic materials. Superselective
catheterization of the left gastric artery (LGA) and/or gastroepiploic artery (GEA) is done, followed by injection of particulate embolic agents (PVA or Embospheres of
300–500μm). This procedure is relatively safe without any
signicant adverse events [57, 58].
Available studies have shown a consistent average weight
loss of 8–9% (ranging from 4.8% to 17.2%) following BAE
at 1year. BAE has also shown to improve hemoglobin A1c,
total cholesterol, and HDL-lipoprotein levels [57–59].
Further studies with a larger number of participants are
required to establish its role in managing obesity.
7.8 Conclusion
An immense growth in the eld of embolotherapy has been
noticed in the last two decades. The technologies in embolotherapy will continue to evolve toward a more precise and
controlled delivery of embolic agents. The role of embolo-
therapy is expanding in a variety of clinical scenarios.
Therefore, a detailed knowledge and understanding of the
basic principles and techniques in embolization will facilitate more procedural success and clinical outcomes.
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