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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3869_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword
- •Preface from the Series Editors
- •Preface from the Editors
- •Contents
- •Planning the Procedure
- •Understanding the Underlying Pathological Process
- •Understanding the Role of Alternative Therapies
- •Contributors
- •Section I
- •1 Basic Principles of Embolization
- •Introduction
- •Underlying Principles
- •Identifying the Target
- •Knowing the Arterial Anatomy and Collateral Pathways
- •Normal Anatomy and Anatomic Variations
- •Collateral Perfusion
- •End Arterial Supply
- •Choosing the Correct Embolic Material
- •Understanding the Likely Outcomes/Consequences of Embolization
- •Performing the Procedure
- •Informing Others: The Patient and Clinicians
- •Planning Vascular Access
- •Selective Catheterization
- •Single End Hole Catheters
- •Avoiding Wedged Catheter Positions
- •Microcatheters
- •Delivery of Embolic Materials
- •Preserving Vessels
- •Non-target Embolization
- •2 Coils, Occluders, and Plugs
- •Introduction
- •Mechanism of Action
- •Intimal Injury and Thrombus Formation Are Interrelated
- •Physical Properties of Embolization Coils and Plugs
- •Materials
- •Novel Materials
- •Material Issues
- •Thrombogenicity
- •Coils Shapes and Sizes
- •Coil Size
- •Terminology
- •Coil Deployment
- •Additional Techniques
- •Detachable Coils
- •Associated Complications and Strategies for Minimizing These
- •Suggested Further Reading
- •3 Permanent Particulate Agents
- •Introduction
- •Particle Physical Properties
- •Commonly Used Agents
- •Polyvinyl Alcohol Particles (PVA)
- •PVA Microspheres
- •Tris-Acryl Microspheres
- •Bio-active Particles
- •Drug-Eluting Microspheres
- •Two Types of Drug-Eluting Microspheres are Available
- •Considerations Relating to 90 Y Microspheres
- •Detectable Microspheres
- •Using Permanent Particulate Agents
- •Preparation of the Agent
- •Injection of the Agent
- •Following Injection
- •Keypoints
- •4 Temporary Embolic Agents
- •Temporary Agents
- •Autologous Blood Clot
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When and When Not to Use It
- •Detecting and Preventing Problems
- •Gelatin Sponge
- •Slurry
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It (Figure 4.1)
- •When and When Not to Use It
- •Detecting Problems
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When and When Not to Use It
- •Dosage and Side Effects
- •When to Use Absolute Alcohol
- •When Not to Use It
- •Sodium Tetradecyl Sulfate
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When to Use
- •When Not to Use It
- •N-Butyl Cyanoacrylate
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When to Use
- •When Not to Use It
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •Detecting Problems
- •Pledgets
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When and When Not to Use It
- •Detecting Problems
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use It
- •When and When Not to Use It
- •Detecting Problems
- •5 Liquid Embolic Agents
- •Sclerosing Agents
- •Physical Description and Properties
- •Mode of Action
- •How to Prepare and Use Alcohol
- •When to Use
- •When Not to Use It
- •Note
- •Lipiodol
- •Physical Description and Properties
- •Fate of Injected Lipiodol
- •Lymphatic Injection
- •Hepatic Arterial Injection
- •How to Prepare and Use It
- •When to Use
- •When Not to Use It
- •Suggested Reading
- •6 Miscellaneous Embolic Agents: Laser and Radiofrequency
- •Laser
- •About Lasers
- •Laser Power (Fig. 6.2)
- •Safety
- •Radiofrequency (Fig. 6.3)
- •Monitoring Treatment
- •Applications of Temperature-Induced Vessel Occlusion
- •Keypoints
- •7 Future Embolic Therapies
- •Gene Therapy
- •Mode of Action
- •Mechanisms of Gene Transfer/Modulation
- •Nanoparticles
- •Keypoints
- •Recommended Readings/References
- •8 Vascular Access, for Embolization: Techniques and Equipment
- •Catheter Choice
- •Catheter Properties
- •Catheter Shapes and Technical Tips
- •Reverse Curve Catheters
- •Scenarios
- •Crossing the Aortic Bifurcation
- •Technical Note: Waltman Loop Technique
- •Catheter Characteristics
- •Microcatheters
- •Advantages of Microcatheters
- •Disadvantages of Microcatheters
- •Occlusion Balloons
- •Uses of Occlusion Balloons in Embolization
- •Vascular Sheaths and Guiding Catheters
- •Guidewires
- •Support Wires
- •Exchange Wires
- •Keypoints
- •9 Pre-procedure Imaging: When, Why, and How?
- •Introduction
- •Pre-procedure Imaging: When?
- •Pre-procedure Imaging: Why?
- •Pre-procedure Imaging: How?
- •Imaging Technique
- •Contrast Enhancement
- •Clinical Scenarios
- •Thoracic Embolization
- •Hemoptysis
- •Abdominal Embolization
- •Acute Gastrointestinal Hemorrhage
- •Pre-procedure Imaging: When?
- •Pre-procedure Imaging: Why?
- •Trauma (see also Chapter 10)
- •True Aneurysms of the Visceral Arteries
- •Suggested Further Reading
- •10 Imaging the Severely Injured Patient
- •Introduction
- •Death from Trauma
- •Rationale for Early Imaging
- •Optimal Imaging
- •Image Reconstruction
- •What to Look For
- •What Next?
- •Performing Angiography
- •Considerations for Imaging Departments
- •Radiation Considerations
- •Bibliography
- •Appendix
- •11 Safety in the Periprocedural Period
- •Introduction
- •Pre-procedure
- •Procedural
- •Post-procedural
- •Safe Sedation and Analgesia During the Procedure
- •Staff
- •Equipment
- •Routine Care Equipment
- •Emergency Equipment
- •Medications
- •Complications
- •Anesthesiology Assistance During Sedation and the Use of General Anesthesia
- •Safe Sedation and Analgesia Following the Procedure
- •Contrast-Induced Nephropathy
- •Prevention of CIN
- •Patient Safety and Comfort Are Paramount
- •Suggested Readings
- •12 Complications of Embolotherapy
- •Prevention, Detection, and Recognition
- •Pre-procedure
- •During the Procedure
- •Detection and Recognition
- •During the Procedure
- •Post-procedure
- •Clinical Assessment
- •Blood Tests
- •Imaging
- •Catheters Blocking
- •Non-target Embolization
- •Coil Retrieval
- •Tissue Necrosis
- •13 Management of Post-embolization Syndrome
- •Introduction
- •Pathophysiology
- •Clinical Features
- •Pain
- •Fever
- •Nausea and Vomiting
- •Diagnostic Evaluation
- •Laboratory
- •White Cells
- •Management of PES
- •Prevention
- •Management of PES: Intraprocedural
- •Bibliography
- •Section II
- •14 Peripheral Vascular Malformations
- •Background
- •Low-Flow Lesions
- •Clinical Features
- •Diagnostic Evaluation
- •Clinical Review
- •Laboratory
- •Imaging
- •Indications for Embolization
- •Alternative Therapies
- •Cautions/Contraindications
- •Anatomy
- •Medication
- •Angiography
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Follow-Up
- •High-Flow Lesions
- •Diagnostic Evaluation
- •Clinical Review
- •Laboratory
- •Imaging
- •Indications for Embolization
- •Alternative Therapies
- •Cautions/Contraindications
- •Anatomy
- •Equipment
- •Catheters
- •Embolic Agents
- •Medication
- •Angiography
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •15 Pulmonary Arteriovenous Malformations
- •Clinical Features
- •Clinical Presentation
- •Clinical Relevance
- •Clinical
- •Laboratory
- •Imaging
- •Indications
- •Alternative Therapies
- •Contraindications
- •Anatomy
- •Catheters
- •Selective Catheters
- •Embolic Agents
- •Medication
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Aftercare
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Suggested Reading
- •16 Systemic Arteriovenous Fistulae
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Indications for Embolization
- •Alternative Therapies
- •Anatomy
- •Equipment
- •Catheters
- •Medications
- •Pain Control
- •Infection Control
- •Sickness Control
- •Hydration
- •Arterial Access
- •Venous Access
- •Assessing the Lesion
- •Angiographic Appearance
- •Clinical Scenarios
- •Etiology of Arteriovenous Fistulae
- •Renal AVF
- •Small Post-biopsy Renal AVF
- •Congenital and Large Renal Arteriovenous Fistulae
- •Arterioportal Fistuale
- •Aortocaval Fistulae
- •Approach
- •Artery
- •Vein
- •Technical Points
- •Aftercare
- •Arterial Puncture Site
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Suggested Readings
- •17 Klippel-Trenaunay Syndrome
- •Diagnosis
- •Clinical Features
- •Capillary Malformation (Fig. 17.1)
- •Hypertrophy of Bone and Soft Tissues (Fig. 17.1)
- •Venous Abnormality (Fig. 17.2)
- •Other Features
- •Assessment
- •Management
- •18 Biologic Effects of Tumor Embolization
- •Introduction
- •The Target Tissue
- •The Goal of the Embolization Procedure
- •Biological Effects on the Embolized Tissue/Organ
- •Short Term
- •Hypoxia Inducible Factor 1 (HIF-1)
- •Tumor Lysis Syndrome (TLS)
- •Target of Embolization
- •The Patient
- •The Target Organ
- •Liver
- •Kidney
- •The Disease Process
- •Recommended Reading
- •19 Liver Tumors (Hepatocellular Cancer)
- •Epidemiology of HCC
- •Diagnosis
- •Imaging
- •Differential Diagnosis Includes
- •Laboratory/Other Investigations
- •General Considerations
- •Contraindications
- •Pre-procedure Evaluation
- •Anatomic Considerations
- •Normal Anatomy
- •Variant Anatomy: (See also Table 33.1) (Fig. 19.2)
- •Extra-hepatic Supply (Fig. 19.3)
- •Consent
- •Equipment
- •Catheters
- •Chemotherapeutic Agents
- •Embolic Agent
- •Lipiodol
- •Particulate Agents
- •Drug-Eluting Beads
- •Bland Embolization Versus TACE
- •Radioembolization
- •Selective Versus Non-selective TACE
- •Procedure
- •Pre-procedure Preparation
- •Access
- •Initial Diagnostic Study
- •Selective Angiography
- •Perform Chemoembolization
- •Technique: Lipiodol
- •Technique: Drug-Eluting Beads
- •Endpoints: Two Procedural Endpoints Should be Considered
- •Post-procedure
- •Post-procedure Follow-Up
- •Assess
- •Keypoints
- •Suggested Reading
- •20 Liver Tumors: Metastases
- •Clinical Features
- •Available Embolic Therapies
- •Diagnostic Evaluation
- •Indications
- •Relative Contraindications
- •Anatomy
- •Patient Preparation
- •Pre-procedure Medications
- •Equipment
- •Post-procedure Medications
- •Follow-Up
- •Current Data
- •Alternative Therapies
- •Suggested Reading
- •21 Liver Tumors: Neuroendocrine Hepatic Metastases
- •Clinical Features
- •Laboratory
- •Imaging
- •Indications for Embolization
- •Alternative Therapies
- •Contraindications
- •Vascular Anatomy
- •Equipment
- •Catheters
- •Medications
- •IR Evaluation
- •Access
- •Arteriography
- •Assessing the Lesions
- •Angiographic Appearance
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Aftercare
- •Arterial Access Site
- •Post-embolization
- •Follow-Up
- •Suggested Reading/References
- •22 Embolization of Benign and Malignant Renal Tumors
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Indications
- •Contraindications
- •Anatomy
- •Normal Anatomy
- •Aberrant Anatomy
- •Embolic Agents
- •Medication
- •Procedure
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Pre-operative Embolization
- •Embolization in Patients with Inoperable Cancer
- •Embolization in AML
- •Arterial Puncture Site
- •Post-embolization Syndrome
- •Follow-Up
- •Alternative Therapies
- •Keypoints
- •Safety
- •Suggested Reading
- •23 Embolization of Bone Tumors
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging (Fig. 23.1)
- •Indications
- •Alternative Therapies
- •Contraindications (Relative)
- •Anatomy
- •Equipment
- •Catheters
- •Embolic Agents
- •Medication
- •Procedure
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Pre-operative Embolization (Fig. 23.2)
- •Palliative Embolization
- •Embolization as a Primary Treatment
- •Complications
- •Post-embolization Syndrome
- •Follow-Up
- •24 Uterine Fibroid Embolization
- •Clinical Features
- •Diagnostic Evaluation
- •Gynecologic Examination
- •Laboratory
- •Transvaginal Ultrasound (TVUS)
- •Indications
- •Contraindications
- •Aberrant Anatomy
- •Pre-treatment Patient Information
- •Equipment
- •Embolic Agents
- •Medication
- •Procedure
- •Access
- •Angiography
- •Angiographic Appearance
- •Re-embolization of Uterine Artery
- •Arterial Puncture Site
- •Post-embolization Syndrome
- •Follow-Up
- •Treatment Failures
- •Suggested Reading
- •Appendix
- •25 Embolization of Hemorrhage Due to Pelvic Fractures
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging (see also Chapter 10)
- •Indications
- •Contraindications
- •Complications
- •Anatomy
- •Equipment
- •Catheters Required
- •Angiography (See Figs. 25.1 and 25.2)
- •Recommendations
- •Suggested Reading
- •26 Embolization of Extremity Trauma
- •Clinical Features
- •Management Goals
- •Mechanisms of Extremity Vascular Injury
- •Clinical Manifestations of Extremity Vascular Trauma
- •Role of Intervention
- •Diagnostic Evaluation
- •Clinical Evaluation
- •Physical Signs of Vascular Injury
- •Imaging
- •Radiographs
- •Indications
- •Alternative Therapies
- •Anatomy
- •Aberrant Anatomy
- •Variant Anatomy of Lower Extremity
- •Equipment
- •Catheters
- •Non-selective
- •Selective Catheters
- •Guide Catheters and Sheaths
- •Embolic Agents
- •For Dispensable Branch Vessels
- •For Indispensable Vessels
- •Medication
- •Angiography
- •Access
- •Angiographic Appearance
- •Positive Findings of Vascular Injury
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Consider
- •Special Considerations
- •Upper Limb
- •Lower Limb
- •Aftercare
- •Arterial Puncture Site
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •27 Solid Organ Embolization in Trauma
- •Clinical Features
- •Diagnostic Evaluation
- •Clinical
- •The Importance of Blood Pressure in the Context of Trauma
- •Imaging (See Also Chapter 10)
- •Abdominal Ultrasound (FAST)
- •Contrast-Enhanced CT
- •Imaging Findings: The Following Predict the Need for Intervention
- •Indications
- •Alternative Therapies
- •Surgery
- •Contraindications
- •Complications
- •Anatomy
- •Normal Anatomy and Common Variations
- •Equipment
- •Embolic Agents
- •Rarely Required
- •Medication
- •Access
- •Angiography
- •Angiographic Appearance
- •Embolization
- •Liver
- •Complications of Hepatic Embolization
- •Spleen
- •Complications of Splenic Embolization
- •Kidney
- •Complications of Renal Embolization
- •Aftercare
- •Arterial Puncture Site
- •Post-embolization
- •Keypoints
- •28 Post-traumatic Priapism
- •Clinical Features
- •Low-Flow Priapism
- •High Flow or Arterial Priapism
- •Diagnostic Evaluation
- •Laboratory
- •Cavernosal Blood Gas Analysis
- •Imaging
- •Color Doppler Imaging of the Penis
- •Indications
- •For Angiography
- •For Embolization
- •Alternative Therapies
- •Cautions
- •Anatomy
- •Normal Anatomy
- •Aberrant Anatomy
- •Equipment
- •Catheters
- •Embolic Agents
- •Medication
- •Angiography
- •Access
- •Angiography
- •Angiographic Appearance
- •Aftercare
- •Post-embolization
- •Follow-Up
- •Safety
- •Suggested Reading
- •29 Embolization for Pancreatic Bleeding
- •Clinical Features
- •Hemorrhage in Pancreatitis
- •Hemorrhage Following Pancreatic Surgery
- •Imaging
- •Indications for Imaging and Embolization
- •Contraindications
- •Anatomy
- •Angiography and Embolization Equipment
- •Embolic Agents
- •Procedure Access
- •Angiography
- •Angiographic Appearance
- •Embolization for Post-pancreatitis Aneurysm and Pseudoaneurysm
- •Embolization for Post-operative Bleeding
- •Aftercare
- •Puncture Site
- •Post-embolization
- •Follow-Up
- •Safety
- •Bibliography
- •30 Embolization in Post-operative Hemorrhage
- •Clinical Features
- •Diagnostic Evaluation
- •Clinical
- •Laboratory
- •Imaging
- •Indications
- •Alternative Therapies
- •Surgical Repair
- •Alternative Interventional Techniques
- •Contraindications
- •Anatomic Considerations
- •Equipment
- •Medication
- •Systemic
- •Transcatheter
- •Procedure
- •Angiographic Appearance
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Unstable Patients
- •Coagulopathic Patients
- •Active Extravasation
- •Pseudoaneurysm
- •Iatrogenic Injury During Central Line Placement
- •Post-embolization
- •Follow-Up
- •Repeat CT
- •Keypoints
- •Safety
- •Suggested Reading
- •31 Tract Embolization
- •General Concepts
- •Pre-procedure Evaluation
- •Indications for Tract Embolization
- •Contraindications
- •Material Selection
- •Operator Preference
- •Gelfoam
- •Metallic Coils
- •N-Butyl Cyanoacrylate
- •Autologous Clotted Blood/Blood Patch
- •Post-procedure Management
- •Complications
- •Results
- •Keypoints
- •References
- •32 Arterial Embolization Post-percutaneous Biopsy or Drainage
- •General Considerations
- •Bleeding Around Drains
- •Drainage Catheter Upsizing
- •Bleeding Following Biopsy
- •Risk Factors
- •Pre-procedure Evaluation
- •Patient Evaluation
- •Imaging
- •Laboratory
- •Indications for Embolization
- •Contraindications to Embolization
- •Treatment Plan and Technique
- •Pseudoaneuryms and Active Bleeding
- •Materials
- •Catheters and Microcatheters and Guidewires
- •Embolization Materials
- •Medications
- •Complications
- •Anatomy of the Lesion
- •Hematomas
- •Arteriovenous, Arterioportal, or Arteriobiliary Fistulae
- •Pseudoaneurysm
- •Bile Leaks
- •Vascular Anatomy
- •Native Liver
- •Transplanted Livers
- •Procedure/Steps
- •Embolization
- •Results
- •Complications
- •Renal Embolization Post-percutaneous Biopsy/Drainage
- •Anatomy of the Lesion
- •Hematomas
- •Arteriovenous Fistula (see Chapter 16)
- •Pseudoaneurysm
- •Vascular Anatomy
- •Native Kidneys
- •Transplanted Kidneys
- •Procedure/Steps
- •Native Kidneys
- •Transplant Kidneys
- •Results
- •Complications
- •Fatal Complication
- •Procedural Complication
- •Anatomy of the Lesion
- •Source of Bleeding
- •Imaging Findings
- •Vascular Anatomy
- •Procedure/Steps
- •Procedure Preparation
- •Angiography
- •Embolization
- •Results
- •Complications
- •Bibliography
- •33 Acute Nonvariceal Upper Gastrointestinal Hemorrhage
- •Clinical Features
- •Causes
- •Laboratory
- •Endoscopy
- •Imaging
- •Triple-Phase Multidetector Computed Tomography Angiography (CTA)
- •Indications for Embolization
- •Contraindications to Embolization
- •Anatomy
- •Embolic Agents
- •Procedure
- •Treatment Plan
- •Access
- •Angiography
- •Assessing the Lesion
- •Location
- •Gastric Bleeding
- •Duodenal Bleeding
- •Arterial Puncture Site
- •Follow-up
- •Alternative Therapies
- •Bibliography
- •34 Acute Lower Gastrointestinal (GI) Hemorrhage
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Tc-99 M RBC Study
- •Indications
- •Anatomy
- •Normal Anatomy
- •Anatomic Variation
- •Equipment
- •Embolic Agents
- •Medication
- •Procedure
- •Access
- •Treatment Plan and Technique
- •Embolization
- •Follow-Up
- •Alternative Therapies
- •Suggested Reading
- •35 Bronchial Artery Embolization
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Life-Threatening Hemoptysis
- •BAE Should Also Be Considered in
- •Adjunctive and Alternative Therapies
- •Contraindications
- •All Complications Are Minimized by
- •Anatomy
- •Normal Bronchial Artery Anatomy
- •Key Points in Bronchial Arteriography
- •Aberrant/Variant Anatomy
- •Equipment
- •Catheters
- •Non-selective Catheters
- •Selective Catheters
- •Sheaths and Guide Catheters
- •Embolic Agents
- •Medication
- •Infection Control
- •Hydration
- •Angiography
- •Access and Angiography
- •Angiographic Appearance
- •Next, Identify Any Spinal Supply That
- •Embolization
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Arterial Puncture Site
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Suggested Reading
- •36 Pulmonary Hemorrhage (Non-bronchial)
- •Etiology
- •Causes of Pulmonary Arterial Hemorrhage
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Indications
- •Contraindications
- •Catheters
- •Embolic Agents
- •Medications
- •Procedure
- •Pulmonary Angiography
- •Assess Bleeding
- •Embolization
- •Suggested Reading
- •37 Endoleaks Following EVAR
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Indications
- •Alternative Therapies
- •Contraindications
- •Anatomy
- •Normal Anatomy
- •Aberrant Anatomy
- •Catheters
- •Embolic Agents
- •Medication
- •Access
- •Angiography
- •Assessing the Lesion
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Aftercare
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Suggested Readings
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Indications
- •Alternative Therapies
- •Contraindications
- •Anatomy
- •Normal Anatomy
- •Equipment
- •Catheters
- •Medication
- •Angiography
- •Access
- •Angiography
- •Assessing the Iliac Artery
- •Angiographic Appearance
- •Clinical Scenarios
- •Pre-EVAR Embolization
- •Embolization in Patients with IIAA
- •Aftercare
- •Arterial Puncture Site
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Suggested Reading
- •39 Embolization of Visceral Arterial Aneurysms
- •Clinical Features
- •Natural History
- •Clinical Presentation
- •Rupture
- •Splenic Artery
- •Hepatic Artery
- •Celiac Artery
- •Superior Mesenteric Artery
- •Diagnostic Evaluation
- •Clinical
- •Laboratory
- •Imaging
- •Indications for Treatment
- •Contraindications to Treatment
- •Relevant Anatomy
- •Normal Anatomy ( ≈ 50%)
- •Aberrant Anatomy (≈ 44% with One Arterial Variant, ≈ 6% with Two Arterial Variants)
- •Equipment
- •Medication
- •Procedure
- •Alternative Therapies
- •Suggested Reading
- •40 Renal Artery Aneurysms
- •Clinical Features
- •Diagnostic Evaluation
- •Clinical
- •Laboratory
- •Imaging
- •Treatment Indications
- •Contraindications
- •Equipment
- •Procedure
- •Access
- •Angiography
- •Assessing Lesions
- •Forming a Treatment Plan
- •Covered Stent
- •Balloon Remodeling
- •Bare Stent Assisted
- •Primary Coiling
- •Performing the Embolization
- •Embolization Endpoint
- •Immediate Post-procedure Care
- •Long-Term Follow-Up
- •Results
- •Alternative Therapies
- •In Vivo Aneurysmectomy
- •Ex Vivo Resection and Autotransplant
- •Nephrectomy
- •Complications
- •Keypoints
- •Suggested Reading
- •41 Pre-operative Portal Vein Embolization
- •Pre-operative Portal Vein Embolization
- •Clinical Features
- •Laboratory
- •Imaging
- •Indications
- •Contraindications
- •Anatomy
- •Equipment
- •Catheters
- •Embolic Agents
- •Alternatives Include
- •Medications
- •Angiography
- •Access
- •Angiography
- •Embolic Agents
- •Medication
- •Angiography
- •Access
- •Angiography
- •Angiographic Appearance
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Spontaneous Epistaxis
- •Treatment Plan and Technique
- •Additional Considerations
- •Follow-Up
- •Suggested Reading
- •42 Epistaxis
- •Clinical Features
- •Diagnostic Evaluation
- •Nasal Endoscopy
- •Imaging
- •Laboratory
- •Management of Epistaxis
- •Initial Therapy
- •Indications for Embolization
- •Contraindications
- •Anatomy
- •Normal Anatomy
- •Aberrant Anatomy
- •Equipment
- •Catheters
- •Hereditary Hemorrhagic Telangiectasia
- •Trauma Including Traumatic Pseudoaneurysms
- •Aftercare
- •Arterial Puncture Site
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Bibliography
- •43 Meningiomas and Paragangliomas
- •Clinical Features
- •Diagnostic Evaluation
- •Laboratory
- •Imaging
- •Indications
- •Contraindications
- •Alternative Therapies
- •Anatomy
- •Normal Anatomy
- •Aberrant Anatomy
- •Strategy
- •Equipment
- •Embolic Agents
- •Medication
- •Procedure
- •Access
- •Angiography
- •Location
- •Angiographic Appearance
- •Treatment Plan and Technique
- •Arterial Puncture Site
- •Post-embolization Syndrome
- •Follow-Up
- •Keypoints
- •Safety
- •Clinical Features
- •Diagnostic Evaluation
- •Imaging/Investigation
- •Females with Pelvic Pain
- •Males with Varicocele
- •Indications
- •Females
- •Males
- •Male Varicocele
- •Contraindications
- •General
- •Complications
- •Anatomy
- •Normal Anatomy
- •Female
- •Male
- •Aberrant Anatomy
- •Catheters
- •Embolic Agents
- •Medication
- •Venography
- •Access
- •Venography
- •Transfemoral Route
- •Angiographic Appearance
- •Ovarian Vein
- •Spermatic Vein
- •Clinical Scenarios
- •Treatment Plan and Technique
- •Ovarian Vein
- •Spermatic Vein
- •Aftercare
- •Post-embolization
- •Follow-Up
- •Keypoints
- •Safety
- •Suggested Readings
- •45 Varicose Veins
- •Clinical Features
- •Natural History of Varicose Veins
- •Diagnostic Evaluation
- •Imaging
- •Indications for Treatment
- •Surgery
- •Contraindications
- •General Complications of Venous Ablation Therapy
- •Anatomy and Physiology
- •Normal Venous Anatomy
- •Normal Lower Limb Venous Physiology
- •Equipment
- •Imaging
- •Needles
- •Guidewires
- •Catheters/Introducer Sheaths
- •Miscellaneous
- •Medication
- •Treatment Plan and Technique
- •Thermal Ablation Therapy
- •Laser Therapy
- •Laser Equipment
- •Access
- •Treatment Technique
- •Radiofrequency Ablation Therapy
- •Radiofrequency Devices
- •Technique
- •Foam Sclerotherapy
- •Clinical Scenarios
- •Varicosities
- •Foam Sclerotherapy
- •Avulsions
- •Prominent Veins in Other Sites
- •Aftercare
- •Follow-Up
- •Safety
- •Suggested Reading
- •46 Lymphatic Malformations: Sclerotherapy
- •Clinical Features and Presentation
- •Occurrence
- •Manifestations
- •Diagnostic Evaluation
- •Imaging
- •Other Cystic Lesions in the Head and Neck
- •Treatment Options
- •Evidence for Sclerotherapy
- •Anatomy
- •Equipment
- •Catheters
- •Bleomycin
- •Doxycycline
- •Medication
- •Treatment Plan and Technique
- •Children
- •Technique
- •Follow-Up
- •Safety
- •Recommended Further Reading
- •47 Thoracic Duct Embolization
- •Diagnostic Evaluation/Laboratory
- •Imaging
- •Indications
- •Medical Therapies
- •Contraindications
- •Anatomy
- •Anatomic Variation
- •Equipment
- •Embolic Agents
- •Procedure
- •Preparation
- •Pedal Lymphography
- •Access
- •Treatment Plan and Technique
- •Embolization
- •Disruption of Lymph Channels
- •Case Example (Fig. 47.2)
- •Follow-Up
- •Suggested Reading
- •48 Post-partum Hemorrhage: Embolization and Endovascular Management
- •Clinical Features
- •Diagnostic Evaluation
- •Imaging
- •Indications for Intervention/Embolization
- •Contraindications to Intervention/Embolization
- •Anatomy
- •Equipment
- •Embolic Agents
- •Procedure
- •Therapeutic Embolization for Acute PPH
- •Access
- •Angiography
- •Embolization (See Fig. 48.1)
- •Prophylactic Interventions
- •Access
- •Angiography
- •Embolization
- •Arterial Puncture Site
- •Follow-Up
- •Alternative Therapies
- •Suggested Reading
- •Index
40 Renal Artery Aneurysms 401
• Angiography separate to the embolization procedure may be necessary for
complex aneurysms.
• Choose a treatment plan appropriate to the aneurysm.
• Do not forget to totally exclude the neck of the aneurysm.
• Call for help or refer if uncomfortable (Figs. 40.1, 40.2, 40.3, and 40.4)
Fig. 40.1 Schematic showing
balloon assisted remodeling
for a wide-necked RAA.
Depending on the location
and the size of the aneurysm
neck vis-a-vis the sac, direct
coiling may also work for
these aneurysms
A B
Fig. 40.2 Schematic showing direct coiling of aneurysm with detachable coils (a)andstent-
assisted coiling (b)
402 M.J. Lee
Fig. 40.3 Sixty-four-year-old
female with incidentally
discovered 2.7-cm RAA on a
background of FMD (a).
Proximal and distal landing
zones were adequate for a
covered stent. (b)AGore
Viabahn-covered stent (6 mm
tapering to 4 mm distally)
was placed to exclude the
RAA
a
b
40 Renal Artery Aneurysms 403
Fig. 40.4 Forty-four-year-old
female with FMD and
incidentally discovered RAA.
The RAA measured 3.2 cm
and the neck 1.3 cm. Note
that it also is arising at a
trifurcation. (a) Coiling using
a microcatheter was
performed and the aneurysm
packed and excluded with
detachable coils; (b) 6-month
follow-up angiogram was
stable
a
b
404 M.J. Lee
Suggested Reading
Abath C, Andrade G, Cavalcanti D, Brito N, Marques R. Complex renal artery aneurysms: Liquids
or coils? Tech Vasc Intervent Radiol 2007;10:299–307.
Bastounis E, Pikoulis E, Georgopoulos S, Alexion D, Leppaniemi A, Boulafendis D. Surgery for
renal artery aneurysms: A combined series of two large centers. Eur Urol 1998;33:22–27.
Garg N, Pipinos II, Longo M, Thorell WE, Lynch TG, Johanning JM. Detachaable coils for repair
of extraparenchymal renal artery aneurysms: An alternative to surgical therapy. Ann Vasc Surg
2007;21:97–110.
Hislop SJ, Patel SA, Abt PL, Singh MJ, Illig KA. Therapy of renal artery aneurysms in New
York State: Outcomes of patients undergoing open and endovascular repair. Ann Vasc Surg
2009;23:194–200.
Manninen HI, Berg M, Vanninen RL. Stent-assisted coil embolisation of wide-necked renal artery
bifurcation aneurysms. J Vasc Radiol 2008;19:487–492.
Nosher JL, Chung J, Brevetti LS, Graham AM, Siegel RL. Visceral and renal artery aneurysms: A
pictorial essay on endovascular therapy. Radiographics 2006;26:1687–1704.
Chapter 41
Pre-operative Portal Vein Embolization
Trevor Cleveland
Pre-operative Portal Vein Embolization
Clinical Features
• The most common indications for the procedure are localized metastatic liver
invasion or primary liver tumor.
• Portal vein embolization is performed in patients undergoing liver resection in
whom the residual liver volume will not provide sufficient function (Fig. 41.1).
• This may be because the remaining (usually the left) lobe of the liver is small or
because the resection needs to be extensive (extended hepatectomy).
• The intention of embolization is to divert portal venous blood flow from the liver
to be resected into the segment that will remain following resection.
• This increased perfusion carries growth factors and hormones, stimulating the
residual liver to hypertrophy.
• The lobe containing the cancer will be the one embolized.
• The procedure is performed 4 to 6 weeks prior to the definitive liver resection to
allow hypertrophy.
Fig. 41.1 CT showing tumor in right lobe of liver (black arrowhead) and small left lobe of the
liver (white arrowheads)
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_41,
C
Springer-Verlag London Limited 2010
405
406 T. Cleveland
Diagnostic Evaluation
Laboratory
• The procedure is performed transhepatically; hence, all patients should have their
clotting status checked and corrected prior to embolization.
• Renal function with conventional renoprotection if indicated.
Imaging
Use contrast-enhanced CT and or MRI to
• Identify the location of the diseased segment/s
• Assess the size and location of the liver that will remain following the planned
surgery
• Demonstrate patency of the portal venous system
• Plan the likely approach for percutaneous access
• Assess for ascites
• Identify any evidence of other distant metastatic disease. This is essential as new
disease is common in this group of patients, and may preclude the surgery making
portal vein embolization contraindicated.
Indications
• Metastatic colorectal cancer, localized to the liver (right lobe), for which surgical
resection is planned. This procedure is indicated if the remaining segment/s of
the liver are judged to be insufficient in size to be compatible with survival in the
post-operative period.
• Primary liver tumor, for which resection is planned, when the remaining liver is
considered to be inadequate.
Contraindications
• Metastatic disease outside the liver – this is a contraindication to resection.
• Sufficient healthy liver to sustain function following the planned resection.
• Ascites: as with any transhepatic procedure, this is not an absolute contraindica-
tion; the ascites can be drained. The etiology must be considered as
◦ Embolization will exacerbate portal hypertension
◦ Portal vein occlusion is a contraindication to surgery
◦ Malignant ascites is a contraindication to surgery
41 Pre-operative Portal Vein Embolization 407
• Severely deranged clotting: this indicates that there is already insufficient synthetic hepatic function.
Specific Complications
Embolic material should not be introduced into segments that are to be retained.
This may become difficult as the flow to the lobe for embolization becomes slow
as embolization progresses. If glue or particles are injected into the incorrect lobe,
there is little that can be done to reverse this. Coils can be retrieved using a snare.
Anatomy
• The segmental anatomy of the liver and portal vein variations should be understood.
• The confines of the planned resection should be discussed with the referring
surgeon.
• The pre-procedural imaging should be used to plan the extent of the portal venous
system for embolization.
• The portal venous system will be accessed percutaneously. The position and
size of the hepatic lobes, the portal veins, and the diseased liver should all be
ascertained from the pre-procedural imaging.
• Metastases are almost always situated in the right lobe of the liver, and the left
lobe will be small (otherwise pre-operative portal vein embolization will not be
necessary). The relationship of the liver, the rib cage, and the pleura should be
considered, from the perspective of percutaneous access.
Equipment
• Ultrasound of sufficient quality to visualize the portal vein and needle.
• A micro-puncture set.
Catheters
• 4–5F vascular sheath with radiopaque tip. The sheath must be long enough to
reach and be stable in the portal branch (Fig. 41.2).
• Selective catheters with and without side holes for portal venography and portal
vein catheterization and embolization.
◦ Contralateral lobe puncture: Berenstein, Cobra, Headhunter, multi-purpose
◦ Ipsilateral lobe access: Sidewinder/Simmonds, SosOmni (Fig. 41.3)
• If using glue, ensure that the catheter hub is not polycarbonate.
408 T. Cleveland
a
b
Fig. 41.2 (a) Portal venogram obtained via sheath inserted into left portal vein. The majority of
flow enters the larger right lobe. Left portal vein puncture allows ready access to all right liver
segments. (b) Completion venogram post-embolization shows blood flow directed into the left
lobe of the liver with no flow into the periphery of the right lobe
Embolic Agents
The intention of the embolization is to completely stop flow in the portal vein to the
segments that are to be removed. This diverts blood flow (containing growth factors
and hormones) to the remaining liver, stimulating it to hypertrophy.
• Cyanoacrylate glue: it is the preferred agent. Portal vein embolization is a
relatively safe procedure and is a good opportunity to learn how to use glue.
41 Pre-operative Portal Vein Embolization 409
Fig. 41.3 Coil embolization of the access segment (white arrowhead) as the catheter (black
arrowhead) is withdrawn
◦ Glue is effective, efficient, and low cost in Europe (although expensive in the
United States) (Fig. 41.4).
◦ Cyanoacrylate glue should be mixed with Lipiodol (proportions 1:2.5).
◦ 5% Dextrose solution is needed to flush catheters and to prevent pre-mature
setting of the glue.
Fig. 41.4 Embolization of the right lobe of the liver via ipsilateral puncture using a sidewinder
catheter
410 T. Cleveland
Alternatives Include
• Particulate materials: Gelfoam and PVA may be used for embolization. The vol-
ume to be embolized is large, so large particles should be used. Remember that
Gelfoam is a temporary agent and must be combined with coils.
• Coils: these are often combined with Gelfoam to ensure permanent occlusion.
• Amplatzer vascular plugs: these are relatively expensive, and may require a fairly
large-diameter delivery device.
Medications
• Sedation and systemic analgesia: access for this procedure may be painful, and
a benzodiazepine (such as midazolam) and opiate should be administered. There
is usually little pain following the procedure.
• Local anaesthesia is used for the percutaneous access.
Angiography
Access
The access point is chosen according to the segments to be embolized based on the
planned resection and pre-procedural imaging.
• The patient is positioned in an angiographic suite, with their right arm above their
head.
• Use ultrasound to image the target portal access site and target the percutaneous
puncture.
• The puncture may be made either in the lobe to be preserved or in the lobe to be
resected.
• The vascular sheath is positioned in the portal venous branch. Once this has been
achieved, it is often helpful to suture the sheath in place.
Angiography
• A portal venogram should be performed by passing a catheter with side holes into
the main portal vein, followed by a hand injection of contrast (Fig. 41.2).
• It is essential to identify the portal venous anatomy with certainty.
• AP and oblique projections may be necessary.
• Comparison with multi-planar reformats of CT/MR images may help with
orientation.
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