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Technical Considerations for Microcatheter Use
A 1-mL or 2.5-mL Luer Lock syringe is recommended when GS is injected
through a microcatheter.16 In addition, the injection of normal saline between
GS injections is recommended to avoid clogging of the microcatheter. Care
should be taken when larger particles (>2 mm) are used because
fragmentation can occur after the microcatheter is passed, resulting in very
small particles and a more distal embolization than intended.
17
Size and Distribution in the Vessels
The size of the GS is not uniform in both manually prepared GS sheets and
preshaped GS.
14,17,18
Specifically for the sheet-shaped GS, the size and
uniformity of the particles largely depend on the preparation technique.
Hand-cut GS is uniform in size, whereas the pumping technique produces
particles with various sizes.18 Katsumori and Kasahara18 reported that cutting
produced lower rates of smaller particles (≤500 μm) and larger particles
(>2,000 μm) than pumping (8.5% vs. 20.4% and 0% vs. 48.1%, respectively)
when Gelfoam was used.
Similar to other embolic materials, the vessel distribution after GS
embolization depends on the size of GS. Although GS is deformable, it has
the tendency to embolize vessels that are smaller than its size. Moreover,
calibrating the size of GS particles is difficult not only for manually prepared
sheet-shaped GS but also for preshaped 1-mm and 2-mm diameter GS.19 In
theory, this represents the disadvantages of GS use, as the level of
embolization is difficult to control. In animal studies, when 1- to 2-mm handcut and preshaped GS were used, the mean diameter of the occluded vessels
was approximately 500 μm.
14,20
In an animal study by Miyamoto,21 GS
particles prepared by pumping were distributed in a wide range of porcine
uterine arteries, including vessels less than 100 μm in diameter.
CLINICAL APPLICATIONS
GS has been used extensively in various disease entities (Table 5.1). It has
been used as antitumor treatment for hypervascular tumors and to control
bleeding in various types of hemorrhages. Although data from randomized
controlled comparative trials with newer spherical embolic materials are
limited, the use of GS as a standard embolic material is supported by wide
clinical experience and various clinical reports.
Hepatocellular Carcinoma
Transarterial chemoembolization (TACE) for intermediate stage
hepatocellular carcinoma (HCC) using GS has led to improved clinical
outcome by prolonging survival in randomized controlled trials
22,23
and
meta-analyses.
24–26
The use of GS as a temporary agent in HCC is preferred
because of the necessity to repeat TACE for residual, recurrent, and newly
developed tumors.
Although the use of spherical embolic materials and drug-eluting beads
is emerging in many countries, the use of TACE as a standard procedure
remains controversial because its use is not fully evidence-based. TACE with
iodized oil (Lipiodol, Ethiodol) and anthracycline agents followed by
embolization with GS was developed in Japan in the 1980s.
27–29
This is still a
standard technique of performing TACE for HCC in Asian countries, and a
recent prospective study by Ikeda et al.30 demonstrated a favorable 2-year
survival rate of 75.0%. Key features of this technique include super selective
TACE and use of iodized oil to block the draining route and surrounding
portal blood flow of the tumor.
30,31
Postpartum Hemorrhage
Brown et al.32 first reported a case of embolization with GS for postpartum
hemorrhage (PPH) in 1979. Arterial embolization is now widely used for
PPH, with a reported clinical efficacy of 72% to 100%.
33–35
For arterial
embolization of PPH, the main embolic material has been GS because it
causes temporary occlusion of the vessel, which may prevent damage to the
normal uterine parenchyma and may be sufficient to prevent further bleeding
in most cases. Previous clinical studies showed that menstruation resumed in
93% to 100% of patients after embolization with GS.
35–37
In this case, 1- to
2-mm hand-cut or preshaped GS was used because smaller particles are likely
to cause ischemic complications.
Uterine Fibroid Embolization
UAE for the treatment of symptomatic uterine fibroid was first described by
Ravina et al.38 in 1995. Over the past decade, UAE has been increasingly
used, and because of its efficacy and safety, it was established as an
alternative to surgery as standard treatment.
39–42
The use of an embolic
material for UAE has been evaluated, and spherical embolic materials such as
Embosphere are the standard in countries where access to them is
feasible.
43,44
GS has been used as an alternative in countries where these
materials are either not accessible or not preferred for cost-saving reasons.
Katsumori et al.
45,46
first described a large case series of UAE with GS with
favorable mid- and long-term outcomes in terms of symptom improvement in
96% of patients at 1 year, 94.5% at 2 years, and 89.5% at 5 years. A
prospective multicenter study by Sone et al.47 demonstrated a similar
outcome at 1 year with an improvement in menorrhagia in 90% of patients,
bulk symptom in 76%, and pelvic pain in 96%. Depending on the situation,
the use of GS as an alternative embolic material for UAE can be considered.
TIPS AND TRICKS
• GS is applicable to a wide range of disease entities.
• GS is flexible in size depending on the preparation technique.
Ultimately, this will determine the level of occlusion with the target
vasculature.
POTENTIAL COMPLICATIONS
There have been two reports of rare anaphylactic reactions during surgical
use of GS.
48,49
To date, only one study demonstrated anaphylaxis presumably
caused by GS during TACE with cisplatin and GS, without contrast
material.50 Additional complications include nontarget embolization,
ischemia, infection, and postembolization syndrome; however, these are
related to the organ and vascular bed being targeted for embolization and are
not specific to GS.
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