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xiv Contents
13 Management of Post-embolization Syndrome ............ 129
Sapna Puppala
Section II
14 Peripheral Vascular Malformations .................. 137
Peter Littler and Peter Rowlands
15 Pulmonary Arteriovenous Malformations .............. 147
Graham Robinson
16 Systemic Arteriovenous Fistulae ................... 157
Robert Rosen
17 Klippel-Trenaunay Syndrome ..................... 173
Peter Gaines
18 Biologic Effects of Tumor Embolization ............... 179
Erik Cressman
19 Liver Tumors (Hepatocellular Cancer) ................ 185
Jai Patel
20 Liver Tumors: Metastases ....................... 197
Ahsun Riaz and Riad Salem
21 Liver Tumors: Neuroendocrine Hepatic Metastases ......... 205
Kenneth J. Kolbeck and John A. Kaufman
22 Embolization of Benign and Malignant Renal Tumors ....... 215
David O. Kessel
23 Embolization of Bone Tumors ..................... 223
Eric J. Hohenwalter, William S. Rilling, and David M. King
24 Uterine Fibroid Embolization ..................... 231
Sriharsha Athreya and Jon G. Moss
25 Embolization of Hemorrhage Due to Pelvic Fractures ........ 241
Douglas Coldwell and Clayton Trimmer
26 Embolization of Extremity Trauma .................. 249
Tanya Tivorsak and Catherine Vu
27 Solid Organ Embolization in Trauma ................. 261
Otto van Delden
28 Post-traumatic Priapism ........................ 275
Peter Littler, Peter Rowlands, and Richard McWilliams
29 Embolization for Pancreatic Bleeding ................. 283
Tony Nicholson
Contents xv
30 Embolization in Post-operative Hemorrhage ............. 293
Kim Wright and Ben English
31 Tract Embolization ........................... 305
George Behrens and Nilesh H. Patel
32 Arterial Embolization Post-percutaneous Biopsy or Drainage ... 311
George Behrens and Nilesh H. Patel
33 Acute Nonvariceal Upper Gastrointestinal Hemorrhage ...... 329
Ian Gillespie and Hamish Ireland
34 Acute Lower Gastrointestinal (GI) Hemorrhage ........... 341
Brian Funaki
35 Bronchial Artery Embolization .................... 349
Simon McPherson
36 Pulmonary Hemorrhage (Non-bronchial) .............. 363
Hamed Aryafar and Thomas Kinney
37 Endoleaks Following EVAR ...................... 371
Stephen Johnson, Jennifer Fraser, and Rajan Gupta
38 Internal Iliac Artery—Isolated Aneurysm and Pre-EVAR
Embolization .............................. 377
David O. Kessel
39 Embolization of Visceral Arterial Aneurysms ............ 383
A.N. Keeling
40 Renal Artery Aneurysms ........................ 395
M.J. Lee
41 Pre-operative Portal Vein Embolization ............... 405
Trevor Cleveland
42 Epistaxis ................................. 415
Anthie M. Papadopoulou and Andrew Platts
43 Meningiomas and Paragangliomas .................. 425
H.L.D. Makalanda and Andrew Platts
44 Gonadal Vein Reflux: Varicocele and Pelvic Congestion ...... 435
Lindsay Machan
45 Varicose Veins .............................. 445
David West
46 Lymphatic Malformations: Sclerotherapy .............. 459
Richard J.T. Owen
47 Thoracic Duct Embolization ...................... 471
Jess Campagna and Raj Jain
xvi Contents
48 Post-partum Hemorrhage: Embolization and Endovascular
Management .............................. 481
P. Anondo Stangl
Index ..................................... 489
Contributors
Hamed Aryafar MD Department of Radiology (Interventional), University of
California San Diego, San Diego, CA, USA
Sriharsha Athreya FRCS FRCR McMaster University Faculty of Health
Sciences and St Joseph’s Healthcare, Hamilton, ON, Canada
George Behrens MD Department of Interventional Radiology, Rush University
Medical Center, Chicago, IL, USA
Mark Brinckman MD Department of Radiology, University of Colorado, Aurora,
CO, USA
Jess Campagna MD BS Department of Radiology, University of Colorado
Denver, Aurora, CO, USA
Nicholas Chalmers MA MB ChB FRCR Radiology Department, Manchester
Royal Infirmary, Manchester, UK
Trevor Cleveland BMedSci BM BS FRCS FRCR Sheffield Vascular Institute,
Sheffield Teaching Hospitals, Sheffield, UK
Douglas Coldwell PhD MD, Department of Radiology, Jane Phillips Medical
Center, Bartlesville, OK, USA
Erik Cressman PhD MD Department of Radiology, University of Minnesota
Medical Center, Minneapolis, MN, USA
Benjamin English MD Department of Diagnostic Radiology, University of
Colorado Health Sciences, Aurora, CO, USA
Audrey Fohlen MD Department of Radiology, Centre Hospitalier Universitaire de
Caen, Caen, France
Jennifer Fraser BA Department of Radiology, University of Colorado,
Centennial, CO, USA
Brian Funaki MD, Department of Radiology, University of Chicago Medical
Center, Chicago, IL, USA
xvii
xviii Contributors
Peter Gaines MBChB FRCP FRCR, Sheffield Vascular Institute, Northern
General Hospital, Sheffield, UK
Ian Gillespie MB ChB DMRD FRCSEd FRCR Department of Radiology,
Edinburgh Royal Infirmary, Edinburgh, UK
Rajan Gupta MD BSE Department of Interventional Radiology, University of
Colorado Denver, Aurora, CO, USA
Eric J. Hohenwalter MD Department of Radiology/Vascular and Interventional
Radiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital,
Milwaukee, WI, USA
Hamish Ireland MB ChB MRCP FRCR Department of Radiology, Edinburgh
Royal Infirmary, Edinburgh UK
James Jackson MRCP FRCR Department of Imaging, Hammersmith Hospital,
London, UK
Raj Jain MD Department of Radiology, University of Colorado Denver, Aurora,
CO, USA
Stephen Johnson MD, DOVT, CPMG Medical Group, Golden, CO, USA
John A. Kaufman MD Dotter Interventional Institute, Oregon Health and Science
University, Portland, OR, USA
Aoife N. Keeling FFR RCSI MRCPI MSc Department of Radiology,
Northwestern Memorial Hospital, Chicago, IL USA
David O. Kessel MA MRCP FRCR Department of Imaging, Leeds Teaching
Hospitals NHS Trust, Leeds, UK
David M. King MD Department of Orthopedic Surgery, Medical College of
Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, WI, USA
Thomas Kinney MD MSME FSIR Department of Radiology, UCSD Medical
Center, San Diego, CA, USA
Kenneth J. Kolbeck MD PhD Dotter Interventional Institute, Oregon Health and
Science University, Portland, OR, USA
Kimi Kondo DO Department of Radiology, Division of Interventional Radiology,
University of Colorado Denver, Aurora, CO, USA
Michael J. Lee MD Department of Radiology, Beaumont Hospital, Dublin,
Ireland
Peter Littler MRCP FRCR Department of Radiology, Royal Liverpool University
Hospital, Liverpool, UK
Louis Lucas MD Department of Radiology, University of Colorado Health
Sciences Center, Aurora, CO, USA
Contributors xix
Lindsay Machan MD Department of Radiology, University of British Colombia
Hospital, Vancouver, Canada
Hegoda L.D. Makalanda MBBS BSc MRCS FRCR, Department of Radiology,
The Royal Free Hospital, London, UK
Simon McPherson BSc MBBS MRCR FRCR Department of Radiology, Leeds
Teaching Hospitals NHS Trust, Leeds, UK
Richard McWilliams Department of Radiology, Royal Liverpool University
Hospital, Liverpool, UK
Robert Morgan MB ChB MRCP FRCR Department of Radiology, St Georges
NHS Trust, London, UK
Jon Moss FRCS FRCR Department of Radiology, Gartnavel General Hospital,
Glasgow, UK
Tony Nicholson BSc MSc MB ChB FRCR, Department of Radiology, Leeds
Teaching Hospitals, Leeds, UK
Kevin O’Reagan MB BCh BAO BMedSci MRCPI FFRRSCI, Department of
Radiology, Cork University Hospital, Cork, Ireland
Richard J.T. Owen MB BCh Department of Diagnostic Imaging, University of
Alberta, Edmonton, AB, Canada
Anthie M. Papadopoulou BSc MBBS FRCR Department of Radiology, Royal
Free Hospital NHS Trust, London, UK
Jai Patel MB ChB MRCP FRCR Department of Radiology, The Leeds Teaching
Hospitals NHS Trust, St James’ University Hospital, Leeds, UK
Nilesh H. Patel MD FSIR Vascular and Instrumental Program, Central DuPage
Hospital, Winfield, IL, USA
Jean-Pierre Pelage MD PhD Department of Radiology, Hôpital Ambroise Paré,
Université Paris Ouest, Boulogne, France
Andrew Platts MB BS FRCS FRCR Department of RadiologyRoyal Free
Hospital NHS Trust, London, UK
Sapna Puppala MBBS MRCS FRCSEd FRCR CBCCT Department of
Radiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
Lakshmi A. Ratnam MBChB MRCP FRCR Department of Radiology,
St George’s Hospital, London, UK
Ahsun Riaz MD Department of Interventional Radiology, Northwestern
Memorial Hospital, Chicago, IL, USA
William S. Rilling MD Department of Radiology, Medical College of Wisconsin,
Froedtert Memorial Lutheran Hospital, Milwaukee, WI, USA
xx Contributors
Iain Robertson MBChB MRCP FRCR Department of Imaging, Gartnavel
General Hospital, Glasgow, UK
Graham Robinson MA BM BCh FRCS FRCR, Department of Radiology, Hull
Royal Infirmary, Hull, UK
Robert Rosen MD Department of Interventional Cardiology, Lenox Hill Heart
and Vascular Institute, New York, NY, USA
Peter Rowlands FRCP FRCR Department of Radiology, Royal Liverpool
University Hospital, Liverpool, UK
Riad Salem MD MBA Department of Interventional Radiology, Northwestern
Memorial Hospital, Chicago, IL, USA
P. Anondo Stangl MD Department of Radiology, Mount Sinai School of
Medicine, New York, NY, USA
Tanya Tivorsak MD Department of Radiology, University of Colorado Denver
Health Sciences Center, Aurora, CO, USA
Clayton Trimmer DO Department of Radiology, University of Texas
Southwestern Medical Center, Dallas, TX, USA
David Tuite FFRRCSI MB BCh BAO BA Department of Radiology, Cork
University Hospital, Cork, Ireland
Otto Van Delden MD PhD Department of Radiology, Academic Medical Center
of the University of Amsterdam, Amsterdam, The Netherlands
Catherine Vu MD Department of Radiology, University of Colorado Denver,
Aurora CO, USA
David West MB ChB FRCR Department of Imaging, University Hospital of
North Staffordshire, Newcastle-under-Lyme, UK
Kimberley Wright MD Department of Radiology, University of Colorado
Denver, Aurora, CO, USA
Stan Zipser MD JD Department of Diagnostic Imaging, Santa Clara Valley
Medical Center, San Jose, CA, USA
Section I
Chapter 1
Basic Principles of Embolization
Iain Robertson
Introduction
Embolization t herapy covers an enormous spectrum of procedures, from simple
varicocoele embolization to occlusion of complex arteriovenous malformations.
Both procedures aim to provide vascular occlusion, but the techniques, equipment,
approach, outcomes, and hazards are very different. This chapter aims to set the
scene for the rest of the book by covering some of the “philosophy” of embolotherapy. Later chapters in this section will deal with specifics of embolic agents and
imaging. The second section covers individual indications.
Underlying Principles
There is no “one size fits all” solution to embolization, and success is dependent
on adapting the procedure to account for the unique problems presented by each
patient. Embolization is often technically demanding and mistakes can have serious consequences. It is often impossible to recanalize a vessel or vascular bed
accidentally occluded during treatment.
The aim of every embolization treatment is to deliver effective treatment while
minimizing damage to adjacent structures. This will only occur with careful plan-
ning and execution. The remainder of this chapter will cover concepts which can be
applied across the entire range of embolotherapy.
Knowledge: Before starting any embolization procedure, it is essential to have a
thorough understanding of the following:
• The pathophysiology of the underlying condition
• The role of alternative therapies
• The likely therapeutic outcomes of the various therapies
• The vascular anatomy relevant to the clinical scenario
• The different types of embolic agents and how to use them
• The likelihood of success and recurrence
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_1,
C
Springer-Verlag London Limited 2010
3
4 I. Robertson
• The potential to cause and manage adverse events
◦ target organ dysfunction
◦ collateral (non-target) embolization
◦ post-embolization syndrome
Planning the Procedure
Planning, understanding, good technique, and a high level of vigilance can avoid
many of the complications associated with embolization. Careful planning should
start well in advance of the procedure and has been made easier by the advent of
computed tomography (CT) and magnetic resonance (MR) angiography. The key
elements in planning are as follows:
Understanding the Underlying Pathological Process
The conditions treated by embolization have very different pathophysiological driving processes and have different treatment objectives, and therefore require different
treatment strategies. Broadly speaking
• If the pathology has an ongoing tissue-based process (e.g., inflammatory/
neoplastic), then occlusion is required at small vessel/capillary level to achieve a
durable result.
• When there is a single stimulus to vessel injury (e.g., post-renal biopsy), then
occlusion at arterial level will be enough to produce a durable result, though
reperfusion via collateral pathways needs to be considered.
Understanding the Role of Alternative Therapies
Embolotherapy may be the only one of several therapeutic options for a particular
scenario. It is important to understand the pros and cons of all of the alternative
therapies and for these to be discussed with the referring clinicians and the patient.
As always, there are a range of possibilities as follows:
• Embolization may be complementary to other therapies.
• Embolization may be a vital prelude to other therapy (e.g., surgery).
• Embolization may be the only viable therapy.
• Embolization may not be the optimal therapy.
Which of these is true will depend on the circumstances of the case and the local
expertise. Be flexible, honest, and pragmatic.