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ease of deployment.
REFERENCES
1. Ferro C, Petrocelli F, Rossi UG, et al. Vascular percutaneous
transcatheter embolization with a new device: Amplatzer Vascular Plug.
Radiol Med. 2007;112:239–251.
2. Hill SL, Hijazi ZM, Hellenbrand WE, et al. Evaluation of the Amplatzer
Vascular Plug for embolization of peripheral vascular malformations
associated with congenital heart disease. Catheter Cardiovasc Interv.
2006;67:113–119.
3. Mangini M, Lagana D, Fontana F, et al. Use of Amplatzer Vascular Plug
(AVP) in emergency embolisation: preliminary experience and review
of literature. Emerg Radiol. 2008;14:153–160.
4. Hijazi ZM. New device for percutaneous closure of aortopulmonary
collaterals. Catheter Cardiovasc Interv. 2004;63:482–485.
5. Lagana D, Carrafiello G, Mangini, et al. Indications for the use of the
Amplatzer Vascular Plug in interventional radiology. Radiol Med.
2008;113:707–718.
6. Schwartz M, Glatz AC, Rome JJ, et al. The Amplatzer Vascular Plug
and Amplatzer Vascular Plug II for vascular occlusion procedures in 50
patients with congenital cardiovascular disease. Catheter Cardiovasc
Interv. 2010;76:411–417.
7. Wang W, Li H, Tam MD, et al. The Amplatzer Vascular Plug: a review
of the device and its clinical applications. Cardiovasc Intervent Radiol.
2012;35:725–740.
8. Farra H, Balzer DT. Transcatheter occlusion of a large pulmonary
arteriovenous malformation using the Amplatzer Vascular Plug. Pediatr
Cardiol. 2005;26:683–685.
9. Tabori NE, Love BA. Transcatheter occlusion of pulmonary
arteriovenous malformation using the Amplatzer Vascular Plug II.
Catheter Cardiovasc Interv. 2008;71:940–943.
10. Tuite DJ, Kessel DO, Nicholson AA, et al. Initial clinical experience
using the Amplatzer Vascular Plug. Cardiovasc Intervent Radiol.
2007;30:650–654.
11. Taneja M, Lath N, Soo TB, et al. Renal artery stump to inferior vena
cava fistula: unusual clinical presentation and transcatheter embolization
with the Amplatzer Vascular Plug. Cardiovasc Intervent Radiol.
2008;31(suppl 2):S92–S95.
12. Ringe KI, Weidemann J, Rosenthal H, et al. Transhepatic preoperative
portal vein embolization using the Amplatzer Vascular Plug: report of
four cases. Cardiovasc Intervent Radiol. 2007;30:1245–1247.
13. Brountzos EN, Ptohis N, Grammenou-Pomoni M, et al. High-flow renal
arteriovenous fistula treated with the Amplatzer Vascular Plug:
implementation of an arterial and venous approach. Cardiovasc
Intervent Radiol. 2009;32:543–547.
14. Pech M, Kraetsch A, Wieners G, et al. Embolization of the
gastroduodenal artery before selective internal radiotherapy: a
prospectively randomized trial comparing platinum-fibered microcoils
with the Amplatzer Vascular Plug II. Cardiovasc Intervent Radiol.
2009;32:455–461.
15. Swaans M, Post M, van der Ven H, et al. Transapical treatment of
paravalvular leaks in patients with a logistic EuroSCORE of more than
15%: acute and 3-month outcomes of a “proof of concept” study.
Catheter Cardiovasc Interv. 2012;79:741–747.
16. Gu X, Qian Z, Zhao C, et al. A new class of Amplatzer Vascular Plug
(AVP-IV) delivered through diagnostic catheters: bench testing and invivo assessment (ab). J Vasc Interv Radiol. 2009;20(2)(suppl):S109.
17. Ferro C, Rossi UG, Bovio G, et al. The Amplatzer Vascular Plug 4:
preliminary experience. Cardiovasc Intervent Radiol. 2010;33:844–848.
18. Zhu X, Tam MD, Pierce G, et al. Utility of the Amplatzer Vascular Plug
in splenic artery embolization: a comparison study with conventional
coil technique. Cardiovasc Intervent Radiol. 2011;34:522–531.
19. Abdel Aal AK, Hamed MF, Biosca RF, et al. Occlusion time for
Amplatzer Vascular Plug in the management of pulmonary
arteriovenous malformations. AJR Am J Roentgenol. 2009;192:793–799.
20. Vandy F, Criado E, Upchurch GR Jr, et al. Transluminal hypogastric
artery occlusion with an Amplatzer Vascular Plug during endovascular
aortic aneurysm repair. J Vasc Surg. 2008;48:1121–1124.
21. Uberoi R, Chung D. Endovascular solutions for the management of
visceral aneurysms. J Cardiovasc Surg. 2011;52:323–331.
22. Bulla K, Hubich S, Pech M, et al. Superiority of proximal embolization
of the gastroduodenal artery with the Amplatzer Vascular Plug 4 before
yttrium-90 radioembolization: a retrospective comparison with coils in
134 patients. Cardiovasc Intervent Radiol. 2014;37:396–404.
23. Pech M, Mohnike K, Wieners G, et al. Advantages and disadvantages of
the Amplatzer Vascular Plug IV in visceral embolization: report of 50
placements. Cardiovasc Intervent Radiol. 2011;34:1069–1073.
24. Carrafiello G, Lagana D, Dizonno M, et al. Endovascular ligature of
splenic artery aneurysm with Amplatzer Vascular Plug: a case report.
Cardiovasc Revasc Med. 2007;8:203–206.
25. Widlus DM, Moeslein FM, Richard HM III. Evaluation of the
Amplatzer Vascular Plug for proximal splenic artery embolization. J
Vasc Interv Radiol. 2008;19(5):652–656.
26. Puppala S, Wood A. Re: initial clinical experience using the Amplatzer
Vascular Plug. Cardiovasc Intervent Radiol. 2008;31:444–445.
27. Libicher M, Herbrik M, Stippel D, et al. Portal vein embolization using
the Amplatzer Vascular Plug II: preliminary results [in German]. Rofo.
2010;182:501–506.
28. Yoo H, Ko GY, Gwon DI, et al. Preoperative portal vein embolization
using an Amplatzer Vascular Plug. Eur Radiol. 2009;19:1054–1061.
29. Cil B, Peynircioglu B, Canyigit M, et al. Peripheral vascular application
of the Amplatzer Vascular Plug. Diagn Interv Radiol. 2008;14(1):35–39.
30. Basile A, Marletta G, Tsetis D, et al. The Amplatzer Vascular Plug also
for ovarian vein embolization. Cardiovasc Intervent Radiol.
2008;31(2):446–447.
31. Tapping CR, Ettles DF, Robinson GJ. Long-term follow-up of treatment
of pulmonary arteriovenous malformations with Amplatzer Vascular
Plug and Amplatzer Vascular Plug II devices. J Vasc Interv Radiol.
2011;22:1740–1746.
32. Letorneau-Guillon L, Faughnan ME, Soulez G, et al. Embolization of
pulmonary arteriovenous malformations with Amplatzer vascular plugs:
safety and midterm effectiveness. J Vasc Interv Radiol. 2010;21:649–
656.
33. Lee DW, White RI Jr, Egglin TK, et al. Embolotherapy of large
pulmonary arteriovenous malformations: long-term results. Ann Thorac
Surg. 1997;64:930–940.
34. Wang MQ, Liu FY, Feng D. Management of surgical splenorenal shuntrelated hepatic myelopathy with endovascular interventional techniques.
World J Gastroenterol. 2012;18:7104–7108.
35. Shih CH, Liang PC, Chiang FT, et al. Transcatheter embolization of a
huge renal arteriovenous fistula with Amplatzer Vascular Plug. Heart
Vessels. 2010;25:356–358.
36. Boixadera H, Tomasello A, Quiroga S, et al. Successful embolization of
a spontaneous mesocaval shunt using the Amplatzer Vascular Plug II.
Cardiovasc Intervent Radiol. 2009;33:1044–1048.
37. Singh H, Luthra M, Bharadwaj P, et al. Interventional rerouting of
scimitar vein to left atrium using an Amplatzer Vascular Plug. Congenit
Heart Dis. 2007;2:265–269.
38. Powell S, Narlawar R, Odetoyinbo T, et al. Early experience with the
Amplatzer Vascular Plug II for occlusive purposes in arteriovenous
hemodialysis access. Cardiovasc Intervent Radiol. 2010;33:150–156.
39. Pattynama PM, Wils A, van der Linden E, et al. Embolization with the
Amplatzer Vascular Plug in TIPS patients. Cardiovasc Intervent Radiol.
2007;30:1218–1221.
40. Boudoulas KD, Elinoff J, Resar JR. Bronchopulmonary fistula closure
with an Amplatzer multi-fenestrated septal occluder. Catheter
Cardiovasc Interv. 2010;75:455–458.
41. Koo JH, Park KB, Choo SW, et al. Embolization of postsurgical
esophagopleural fistula with Amplatzer Vascular Plug, coils, and
Histoacryl glue. J Vasc Interv Radiol. 2010;12:1905–1910.
42. Pieper CC, Meyer C, Hauser S, et al. Transrenal ureteral occlusion using
the Amplatzer Vascular Plug II: a new interventional treatment option
for lower urinary tract fistulas. Cardiovasc Intervent Radiol.
2014;37:451–457. doi:10.1007/s00270-013-0662-7.
43. Trerotola SO, Pyeritz RE. Does use of coils in addition to Amplatzer
Vascular Plugs prevent recanalization? AJR Am J Roentgenol.
2010;195:766–771.
44. Milic A, Chan RP, Cohen JH, et al. Reperfusions of pulmonary
arteriovenous malformations after embolotherapy. J Vasc Interv Radiol.
2005;16:1675–1683.
45. Maleux G, Rega F, Heye S, et al. Asymptomatic migration of a firstgeneration Amplatzer Vascular Plug into the abdominal aorta:
conservative management may be an option. J Vasc Interv Radiol.
2011;22:569–570.
G
5
Gelatin Sponge
Miyuki Sone • Yasuaki Arai
elatin sponge (GS) has been used worldwide for more than 40 years
for various embolization procedures. Although it was originally
developed as a surgical hemostatic material in 1945,
1,2
Ishimori et
al.3 reported the first case of vascular embolization with GS for a carotidcavernous fistula in 1967. Since then, GS has been a basic embolic material
that is used in various disease entities such as hypervascular tumors,
bleeding, and preoperative embolization.
DEVICE DESCRIPTION
General Characteristics
GS is prepared from purified porcine or bovine skin gelatin or collagen and
processed with nitrogen to obtain a porous structure. It is biodegradable and
insoluble in water. Although the commercially available products vary
between countries, they are classified into two types based on their shape:
preshaped and sheet-shaped. Preshaped GS (GELITA-SPON IR [Gelita
Medical, Eberbach, Germany], Gelpart [Nippon Kayaku, Tokyo, Japan]) is a
ready-to-use, 1- to 4-mm diameter dry product. Sheet-shaped dry GS
(Gelfoam [Pharmacia & Upjohn, New York, USA], Sponzel [Astellas
Pharma Inc., Tokyo, Japan], GELITA-SPON [Gelita Medical, Eberbach,
Germany], Serescue [Nippon Kayaku, Tokyo, Japan]) requires manual
preparation but is flexible in size and shape and can be used to treat various
target vessels.
Mechanisms of Vessel Occlusion
Vessel occlusion with GS occurs mainly by mechanical obstruction caused
by filling of the vascular lumen with GS and subsequent thrombus
formation.
4
,5
Additionally, GS has hemostatic properties, which shorten
coagulation time and accelerate thrombus formation.
6
Recanalization and Resorption
GS is categorized as a temporary, degradable embolic material because of its
unique features of resorption and vessel recanalization. The advantages of
using degradable embolic materials are the preclusion of retaining foreign
materials and recovery of blood flow in the target vessels. As a result,
repeated embolization can be performed if required in the setting of various
disease entities such as hepatocellular carcinoma or hemoptysis and for
preserving fertility when embolization is used for the control of postpartum
hemorrhage.
Because GS is insoluble in water, it is removed by phagocytosis, as a
foreign body reaction usually occurs within 2 to 6 weeks.7 In animal studies,
the time to vessel recanalization varies between a few days to several
months.
8,9
Louail et al.9 demonstrated that the recanalization rate of the
porcine renal artery was 63% at 7 days and 100% at 14 days after GS
embolization. In a similar study by Maeda et al.,10 the recanalization rate was
79% at 7 days after GS embolization. In a clinical study of uterine artery
embolization (UAE) with GS by Katsumori et al.,11 magnetic resonance
angiography performed at 4 months after UAE demonstrated recanalization
of the ascending uterine artery in 88% of patients. However, there are several
reports of recanalization failure in cases of preoperative embolization or
embolization performed to control bleeding.
12,13
Possible causes of
inconsistency in the timing of recanalization after embolization include the
amount of GS used, the inflammatory reactions induced, and the tissue
necrosis that occurs after embolization. When the amount of GS is larger than
the target vessel diameter, dense accumulation in the lumen may lead to an
irreversible interruption of blood flow. An inflammatory reaction is also
prominent after GS embolization.
4,10,14
The inflammatory cells infiltrate the
vessel wall, resulting in stenosis of the vessel because of the proliferation of
fibroblasts, vasculitis, and acceleration of thrombosis.
4,14,15
Furthermore,
possible tissue necrosis after embolization may affect vessel patency
10
because necrotic areas need fewer vessels than intact areas.
TECHNIQUE
Preparation of Sheet-Shaped Gelatin Sponge
To use sheet-shaped GS in vascular embolization, manual preparation is
required to obtain the specific characteristics of the embolic material.
Commonly used techniques include hand-cut, pumping, and torpedo.
Hand-Cut Method
With this technique, sheet-shaped GS is sliced into four thin sections with a
scalpel (Fig. 5.1A,B). Each section is pressed with the fingers or a Petri dish
to make it thinner (Fig. 5.1C). The section is cut in half with a small straight
scissors, which is then cut, starting from one side, into approximately 1-mm
wide columns without cutting the end (Fig. 5.1D). Subsequently, every
column is cut perpendicularly into small square particles and placed in a Petri
dish filled with contrast material (Fig. 5.1E). The particles are aspirated with
a syringe and transferred to a 1-mm syringe if a microcatheter is being used
for embolization (Fig. 5.1F).
Pumping Method
Thin sections are prepared as described previously in the hand-cut technique.
A section is then cut into 2- to 3-mm wide columns (Fig. 5.2A) and placed in
a 2.5-mL or 5-mL syringe and another syringe is filled with contrast material
(Fig. 5.2B,C). Subsequently, GS is agitated and mixed with contrast material
through a three-way stopcock for 10 to 30 times (Fig. 5.2D).
Torpedo Method
Thin sections are prepared as described in the hand-cut technique. A section
is then cut into columns of the preferred size and a column is twisted with the
fingers to sharpen its edge (Fig. 5.3A,B). These torpedoes are then placed in a
syringe through its tip (Fig. 5.3C), and contrast is aspirated into the syringe as
well.