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Embolization of Visceral Arterial Aneurysms 109
8.7.3.3
Complications
Complications of the embolization procedure
include those of diagnostic angiography with the
addition of aneurysm rupture, nontarget emboli-
zation, splenic infarction, abscess formation, and
rarely sepsis (Fig. 8.5). Total splenic infarction can
occur, which puts the patient at an increased risk
of infection with encapsulated bacteria such as
pneumococcus. Older literature suggests that bland
splenic artery aneurysms rupture at a rate of approx-
imately 2% [30]. However, in pregnant patients, rup-
ture occurs in nearly every case with mortality rates
for mother and fetus 70% and 95% respectively [31].
Obviously, any aneurysm in the pregnant female
should be addressed since over 95% will rupture if
left untreated [30, 32].
After a retrospective review of ten years of expe-
rience, Carr et al. found that 42% of their cases of
VAAs presented with rupture [33]. Half of all the
VAAs were splenic artery aneurysms. Of the splenic
artery aneurysms that were observed, 33% went on
to rupture. This is much higher than the previously
reported 2% rupture rate and reflects the fact that
the patients in the series by Carr et al. suffered
from associated conditions such as hypersplenism,
pancreatitis, abscess, and PAN. The overall mor-
tality rate after rupture was 25% despite surgical
intervention [33]. This would suggest that interven-
tion should be pursued in cases due to associated
conditions since a high rupture rate exists during
observation. Incidental aneurysms can be watched.
Again, no case reports of rupture during manipula-
tion were encountered in the current literature.
8.8
Mesenteric
8.8.1
Incidence
The superior mesenteric a rtery aneur ysm is the thi rd
most common VAA but only accounts for 6% of all
spl an ch ni c a neu ry sm s. It is ty pi ca lly associated wit h
an infectious etiology such as endocarditis. Throm-
bosis and dissection can be seen with these lesions
and patients can present with symptoms of mesen-
Fig. 8.5. a CT of the same patient from Figure 4 demonstrat-
ing a perisplenic abscess. The patient developed fever and an
elevated white cell count one week after embolization. Note
arterial perfusion of a splenic remnant medial to the abscess.
b CT image inferior to that of a demonstrating the coils near
the splenic hilum. Collateral fl ow to the spleen despite com-
plete occlusion of the splenic artery exists. c Inferior aspect
of the abscess distinguishing kidney from the residual spleen.
(Courtesy of James R. Duncan, MD)
a b
c
110
C. B. Glaiberman and M. D. Darcy
teric ischemia or intestinal angina. Aneurysms and
pseudoaneurysms of the remaining mesenteric ves-
sels are rare and present in descending frequency:
celiac, gastroduodenal (GDA) (Fig. 8.6), gastric,
gastroepiploic, and pancreaticoduodenal. There is
no significant gender predilection for mesenteric
aneurysms, and the age range typically spans the
sixth and seventh decades.
Fig. 8.6. a Nonselective angiogram of the celiac axis demonstrating
a pseudoaneurysm of the GDA. b Delayed image that shows persis-
tent contrast within the pseudoaneurysm sac. c Follow-up subtracted
image after coil embolization with a microcatheter. No further fi lling
of the pseudoaneurysm from the GDA is noted. d Selective nonsub-
tracted injection of a duodenal branch demonstrates collateral fi lling
of the pseudoaneurysm that would lead to further hemorrhage. e Final
subtracted image after embolization of the collateral vessel with PVA.
Thrombosis of the feeding vessels has been achieved
a b
c d
e
Embolization of Visceral Arterial Aneurysms 111
8.8.2
Causes
Generally, SMA aneurysms are mycotic, celiac
aneurysms develop from cystic medial degenera-
tion, GDA pseudoaneurysms occur in the presence
of duodenal ulceration, and gastroepiploic and
pancreaticoduodenal aneurysms arise secondary
to inflammatory changes from pancreatitis. Other
causes include polyarteritis nodosa, amphetamine
abuse, and connective tissue disorders.
8.8.3
Risks Posed by the Aneurysm
Ischemia from proximal thrombosis or distal embo -
lization and rupture are significant risks posed by
these types of VAAs. Local infection of adjacent
hematomas and generalized sepsis can occur. Sub-
sequent bowel resection may be required if ischemia
from thrombosis or embolization is severe or revas-
cularization is not possible.
8.8.4
Management
8.8.4.1
Anatomic/Physiologic Considerations
Due to good collateral flow, complete occlusion of
splenic, peripheral hepatic, and gastroduodenal
arteries is well tolerated. Ischemia, stricture, and
infarction of the bowel can result from emboliza-
tion in the peripheral SMA and IMA distributions.
Because of the rich arcade around the pancreatic
head, the GDA can easily reconstitute the celiac axis
via retrograde f low from the SMA. This is beneficial
for preventing ischemia, but can allow persistent
perfusion of aneurysms if both distal and proximal
control is not achieved at the time of embolization.
Often, pseudoaneurysm formation in the pancre-
aticoduodenal, SMA, and IMA distributions is due
to adjacent inflammatory processes such as pan-
creatitis or diverticulitis. (Fig. 8.7) Hematomas in
the mesentery can become abscesses. Even though
microcoils are used in these instances, it is unwise to
implant a stent graft into a potentially infected bed.
8.8.4.2
Technique
Technique will vary significantly depending on the
vascular distribution of the mesenteric aneurysm.
Typically, celiac and proximal SMA aneurysms are
best treated surgically.
Although a common femoral approach is prefera-
ble to that of the brachial artery, a left upper extrem-
ity puncture may be required to negotiate the acute
angles the visceral arteries take from the aorta. A
Sos catheter works well from the groin, and an MPA
is typically all one needs from the arm. Guiding
catheters or sheaths offer support and directional-
ity if access is difficult to maintain.
Fig. 8.7. a Selective angiogram demonstrating a pseudoaneurysm of the sigmoid branch of the IMA due to diverticulitis. b Follow-
up subtracted image demonstrating coil occlusion of both branches that were supplying the large pseudoaneurysm. No ischemia
resulted due to collateral fl ow from internal iliac branches via the hemorrhoidal arteries. (Courtesy of Jennifer E. Gould, MD)
a b
112
C. B. Glaiberman and M. D. Darcy
As long as there is no celiac, proper hepatic, or
SMA origin occlusion, the GDA can be sacrificed.
If the GDA is required to maintain perfusion of the
liver or, if flow into the SMA is dependent upon the
celiac, then direct coiling of GDA pseudoaneurysms
is preferable. This can be accomplished with stent
placement over the aneurysm neck and microcoil
deposition through the interstices via a microcathe-
ter. A small-caliber stent graf t such as a Jostent could
theoretically be used in this situation. However, use
of this device is still not approved by the FDA. Appel
et al. described the placement of a 26-mm stent graft
for humanitarian treatment of a traumatic pseudoa-
neurysm of the SMA [34].
The RIM catheter was specifically designed for
the inferior mesenteric artery. This catheter typi-
cally seats well in the origin, which arises at the
level of the left pedicle of L3. A microcatheter can
then be passed coaxially into the desired branch
and microcoils deposited. Superselective technique
is desired. Although some collateral flow is supplied
to the distal colon via internal iliac branches, care
must be taken when occluding more proximal vas-
cular territories.
8.8.4.3
Results of Embolization
Results of transcatheter embolization of mesenteric
aneurysms appear favorable in the literature, and
technical success has been reported to range from
75% to 100% [1,3,15,18,19,24–27,33,35–42]. However,
many of these studies are not only retrospective and
small, but the mesenteric VAAs are often lumped in
with splenic and hepatic artery aneurysms, making
it difficult to isolate effective treatment rates for
SMA, IMA, and GDA aneurysms independently. The
anatomy and location of the lesion will often dic-
tate the success of embolization. Furthermore, some
case series report the use of different methods, such
as percutaneous thrombin or coil injection versus
transcatheter embolization.
8.8.4.4
Complications
The major complicating factor of embolization
in the mesenteric distribution is bowel ischemia
and infarction. Ischemia can cause strictures and
obstruction whereas infarction can lead to perfo-
ration and sepsis from dead gut. Dissection and
thromboembolic phenomenon can occur during
manipulation. Smaller emboli not seen during the
embolization procedure may become evident a few
hours later and manifest as abdominal pain. This
typically resolves with heparinization, pain man-
agement, bowel rest, and time. If hemorrhage occurs
in the mesentery, abscesses can develop and percu-
taneous drainage may be required.
8.9
Renal
8.9.1
Incidence
Incidence rates of aneurysm formation differ for
the various etiologies of renal artery aneurysms.
However, the literature suggests that incidence rates
range between 0.015% and 9.7% [43]. A classifica-
tion scheme divided into saccular, fusiform, dis-
secting, and pseudoaneurysms has been described
by Poutasse [44,45]. The natural history of these
aneurysms is not well defined in the literature. How-
ever, there are small and large case series that dem-
onstrate low rupture rates ranging from 0% to 14%
[46 –50]. Hubert et al. followed some patients with
solitary aneurysms as large as 4.0 cm for as long as
17 years without rupture [50]. Renal artery aneu-
rysms that are treated surgically are approached by
nephrectomy, ex vivo repair, and auto-transplanta-
tion.
8.9.2
Causes
Typically pseudoaneurysm formation in the renal
artery distribution is iatrogenic or traumatic. Other
causes of aneurysm formation include fibromuscu-
lar dysplasia, polyarteritis nodosa, amphetamine
abuse, angiomyolipoma in the presence or absence
of tuberous sclerosis, and neurofibromatosis.
8.9.3
Risks Posed by the Aneurysm
Rupture is a rare risk of these aneurysms. However,
pregnant women are more prone to rupture just as
with splenic artery aneurysms. Schorn et al. pro-
vided a succinct review of the literature regarding the
Embolization of Visceral Arterial Aneurysms 113
risk of rupture of these lesions [51]. They found one
dated series that described the risk of rupture as high
as 14%. However, many subsequent large autopsy
series demonstrated no instances of rupture when
renal artery aneurysms were present. In their review
of the literature, they also discovered that noncalci-
fied aneurysms were more at risk of rupture.
In cases of FMD, distal embolization and dissec-
tion can be seen. Malignant hypertension may be
the presenting symptom as a result of embolization
of clot from the aneurysm or occlusion from a dis-
section flap.
8.9.4
Management
8.9.4.1
Anatomic/Physiologic Considerations
The vascular supply to the kidney is considered end-
organ, and infarction is common after emboliza-
tion. Therefore, in patients with renal insufficiency
or underlying diseases such as tuberous sclerosis
or von Recklinghausen’s disease, nephron-sparing
procedures are vital. Superselective embolization is
advisable in all cases of renal artery embolization
unless partial or total nephrectomy is planned.
8.9.4.2
Technique
The renal arteries arise at the L2 level from the
abdominal aorta. A 10q LAO view during a flush
injection of the aorta will often provide the best
view of the origins. Careful examination for acces-
sory renal arteries is necessary. A Sos or Cobra
catheter will easily select the main renal ostium. A
Rosen wire is an atraumatic guidewire that allows
for secure exchange or upsizing to a guiding cath-
eter or Balkin sheath. Selective injection should be
performed to identify the feeding vessel or vessels.
This can be done through the sheath.
Many embolization techniques can be used in
this setting depending on the type, number, and
location of the aneurysms. For example, aneurysms
of the main renal artery may be amenable to stent
graft placement, thus allowing distal perfusion to
be maintained [52–56]. However, until stent graft
placement is perfected, surgical repair by resection,
aneurysmorraphy, and autotransplantation is more
commonly performed in this setting.
More peripheral aneurysms can be selectively coil
embolized using microcatheter techniques. Both
distal and proximal control is not always possible,
and may not be necessary due to the vascular anat-
omy. In the presence of multiple aneurysms from a
lesion such as an angiomyolipoma, a combination
of particle and coil embolization can be performed.
If actively bleeding, the aneurysms are coiled first,
followed by occlusion of the feeding vessels to the
tumor with PVA or embospheres. Gelfoam can be
sandwiched between coil nests to assist thrombo-
sis.
If surgical resection is planned, ablation of entire
lobar or main renal arteries can be performed with
ethanol. This requires the use of a balloon occlusion
catheter such as a single lumen Balloon Wedge-Pres-
sure Catheter (Arrow International, Reading, PA) to
prevent systemic spread of alcohol. Ethanol ablation
should be performed within one or two days of the
planned resection. This will help to avoid a pro-
longed post-embolization syndrome, which can be
quite uncomfortable for patients and can reduce the
risk of abscess formation from the ensuing infarc-
tion.
8.9.4.3
Results of Embolization
The technical success is quite high once the renal
artery is securely accessed. If superselective tech-
niques are used, very little ischemia results and
there is very little chance of inducing renal failure.
The small number of reported cases in the literature
makes it difficult to assess the long-term success of
transcatheter embolization.
8.9.4.4
Complications
Although rare, dissection or perforation of the renal
arteries and their branches can occur. Rupture may
lead to rapid development of retroperitoneal hem-
orrhage. Both dissection f laps and rupture can be
immediately controlled with balloon tamponade.
Although dissection f laps can often be tacked down,
rupture typically requires emergent surgery. Even
perforation of smaller branch vessels can occur if
a guidewire is passed too far into the periphery.
Hematoma and abscess can develop.
Embolization of plaque from heavily calci-
fied arteries or aorta is a risk when manipulating
114
C. B. Glaiberman and M. D. Darcy
sheaths or catheters in the origins of these vessels.
Even though richly vascular, the renal parenchyma
is prone to ischemia and infarction due to its end-
organ supply. Every attempt should be made to
become as selective as possible to preserve distal
flow and prevent nontarget embolization.
Care must be taken when embolizing with abso-
lute ethanol due to the vigorous thrombosis it causes
by denaturing proteins. Ethanol can cause seizures
and intoxication if it reaches the systemic circula-
tion. It can a lso permeate the t issues and cause injury
to adjacent structures such as bowel and nerves.
8.10
Complications
Access site complications include hematoma, pseu-
doaneurysm formation, and arterial dissection.
Although sometimes unavoidable, good technique
should keep these complications at an acceptable
level. Brachial punctures are slightly more prone to
complication, especially neural compression from
hematoma. It should also be remembered that work-
ing from the left arm entails a catheter crossing the
origin of the left vertebral artery, and a sheath will
be nearly occlusive in the brachial artery. If pos-
sible, using a smaller sheath such as a 4 or 5 French
system can help diminish post-procedure complica-
tions. Microcatheters will work coaxially through
4 French catheters.
Placement of a vascular sheath serves two impor-
tant purposes. It protects the access artery from
injury if multiple catheter exchanges occur, and it
maintains access to the artery should the working
catheter become occluded.
Aneurysm rupture during vigorous contrast
injection or direct manipulation can occur. Emer-
gent tamponade can be achieved by inflating a bal-
loon either across the neck of the aneurysm or in the
origin of the feeding vessel. Having an appropriately
sized balloon occlusion catheter ready on the back
table can be useful should rupture occur during the
procedure. Emergent surgery may be necessary if
the bleeding cannot be controlled or if permanent
embolization of the parent vessel is not technically
feasible. The ruptured aneurysm may continue to
bleed if distal occlusion is not achieved.
One of the feared complications of deploying
coils, injecting thrombin or glue, or infusing par-
ticulate embolics is nontarget embolization. Strin-
gent technique to ensure satisfactory positioning
of catheters is vital to prevent nontarget emboliza-
tion. Before embolizing, catheter stability should
be tested by passing a wire through it. Catheters are
more apt to buckle out of vessel origins and cause
nontarget embolization or loss of access in the pres-
ence of extremely tortuous courses. Should a coil
become lodged in the catheter, a forceful injection
with a 1- or 3-cc syringe can be attempted to torpedo
it free. However, this maneuver may back the cathe-
ter out of the target vessel. If nontarget embolization
of a coil occurs, a snare can be used in an attempt to
retrieve it if it lodges in an undesirable location.
Since mi niscu le amounts of th rombin are requi red
to thrombose aneurysms, great care should be taken
when injecting this embolic. Distal embolization
during thrombin injection usually resolves without
significant sequelae. Although not always possible
with VAAs, the use of real-time ultrasound can help
to monitor the progress of thrombosis. Obtain-
ing arterial access provides the ability to balloon
occlude the origin of the aneurysm when injecting
the aneurysm percutaneously.
8.11
Future Development and Research
Coil embolization has been one of the mainstays
of VAA treatment and has been augmented with
direct glue or thrombin injection. Coil design has
not changed significantly. However, extremely pre-
cise deployment mechanisms such as electrolytic
detachment are available today.
Many different agents, both temporary and per-
manent (Gelfoam, glue, thrombin, PVA, detachable
balloons, and ethanol) can be used depending on the
situation and the desired end result. There has been
no significant change of these materials in the last
few years. Refinement of PVA into embolic “spheres”
has been achieved, and is thought to provide a more
uniform embolization rather than the clumping that
can occur with regular PVA. A newer nonadhesive
liquid embolic agent called Onyx (Micro Therapeu-
tics. Inc., Irvine, CA) has been used in some neu-
rointerventional and neurosurgery applications.
Because Onyx is nonadhesive, care must be taken
when using this product due to the propensity of the
embolic to migrate into the parent vessel.
The future may lie with stent graft placement,
which has been performed with good technical suc-
cess in the last four years, albeit in small case reports
[16, 34, 52, 54–67]. However, no long-term data exist,
Embolization of Visceral Arterial Aneurysms 115
and further investigation is warranted. The capacity
to occlude aneurysm necks while maintaining distal
perfusion in a single step would seem to make stent
graf ts the ideal therapy. However, small vessel diam-
eter, short landing zones, frequent bifurcations, and
tortuosity provide ample hurdles for placement of
stent grafts in the visceral arteries. Furthermore,
the paucity of these cases makes it difficult to collect
statistically significant data and gain experience in a
short period of time. Therefore, there is little to drive
the market to further develop this technology.
8.12
Conclusion
Although quite rare, visceral artery aneurysms are
life-threatening when hemorrhage occurs. Aggres-
sive management by the interventional radiologist
is paramount. Often, these patients are too sick for
major revascularization procedures, making endo-
vascular techniques a more desirable approach. Sur-
gical morbidity and mortality is fairly high after
aneurysm rupture.
The asymptomatic lesions are being discovered
more regularly due to the increased demand for
cross-sectional imaging. The timing of treatment
depends on a neurysm siz e and location. For ex ample,
some authors have suggested treating asymptomatic
splenic artery aneurysms while others have argued
that observation is adequate [60, 68, 69]. However
observation is the exception rather than the rule
with visceral artery aneurysms. All splenic artery
aneurysms in women of child-bearing age should be
treated due to the high incidence of rupture in the
third trimester. All mesenteric aneurysms should
be treated due to a high likelihood of complications
from rupture, thrombosis, or embolization.
A variety of methods for embolization of VAAs
are described in the literature. The type of treat-
ment should be tailored to each individual case as
the anatomy will typically dictate the therapy best
suited.
Despite the fact that minimally invasive embo-
lization procedures have been performed for over
twenty years, very few long-term data on VAA
occlusion are available. Further investigation and
development of newer techniques such as stent graft
placement are needed. Coil, glue, thrombin, and
particle embolization will continue to be effective
methods for treatment of visceral artery aneurysms
in both the elective and emergent settings. Good
technique and a firm understanding of the visceral
vascular supply are vital, just as in any embolization
procedure.
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Endovenous Thermal Ablation of Incompetent Truncal Veins in Patients with Superfi cial Venous Insuffi ciency 117
Venous Ablation
Endovenous Thermal Ablation of Incompetent Truncal Veins in Patients with Superfi cial Venous Insuffi ciency 119
9 Endovenous Thermal Ablation of Incompetent
Truncal Veins in Patients with Superficial Venous
Insufficiency
Neil M. Khilnani and Robert J. Min
N. M. Khilnani, MD; R. J. Min, MD
Cornell Vascular, Weill Medical College of Cornell University,
416 East 55th Street, New York, NY 10022, USA
of patients with all forms of CVI have significant
superficial venous insufficiency (SVI). If present,
treatment of CVI begins with elimination of this
reflux. Ref lux in the saphenous (truncal) veins is the
most common cause of venous hypertension. Patho-
physiologically significant reflux in the great saphe-
nous vein (GSV) or in one of its primary tributaries
is present in 70%–80% of patients with CVI. Small
saphenous vein (SSV) reflux is found in 10%–20%
and non-saphenous superficial ref lux is identified
in 10%–15% of patients [2, 3].
SVI is certainly the most prevalent medical con-
dition treated by interventional radiologists. Up
to 25% of women and 10% of men in the U.S. are
affected, with 50% of people >50 years old having
some form of SVI [3]. Most patients with SVI have
symptoms, which include aching, fatigue, throb-
bing, heaviness, and night cramps. A minority of
patients develop skin injury from chronic venous
hypertension, which includes eczema, edema, pig-
mentation, lipodermatosclerosis, and ulceration.
Heredity is the primary risk factor for developing
SVI; 85% of patients are affected if both parents are
involved, 47% if one parent is involved, and 20% if
neither parent is involved [4]. Prolonged standing
and multiparity increase the risk of expressing this
heritable risk.
9.3
Anatomy
The superficial venous system of the lower extremi-
ties is composed of innumerable subcutaneous col-
lecting veins, the saphenous trunks and their tribu-
taries. The GSV begins on the anterior and medial
portion of the foot, runs anterior to the medial mal-
leolus, and ascends the medial aspect of the calf and
thigh to ultimately join the femoral vein at the fossa
ovale (saphenofemoral junction, SFJ) several centi-
meters below the inguinal ligament (Fig. 9.1). The
GSV is adjacent to the saphenous nerve (sensory)
CONTENTS
9.1 Introduction 119
9.2 Pathophysiology and Epidemiology 119
9.3 Anatomy 119
9.4 EVTA: Background 120
9.5 Evaluation Prior to EVTA 121
9.6 EVTA Technique 121
9.7 Clinical Data 123
9.8 Summary 125
References 125
9.1
Introduction
Endovenous thermal ablation has become an
accepted option to eliminate the reflux caused by
incompetent saphenous veins. In this chapter, a
review of the clinical problems and anatomy pre-
cedes a review of this exciting new venous occlusion
technique.
9.2
Pathophysiology and Epidemiology
Lower-ex tremity chron ic venous insuff iciency (CVI)
is caused by venous hypertension [1]. Most patients
develop venous hypertension from the hydrostatic
forces produced by ref lux that results from primary
valvular insufficiency [2] Venous obstruction, mus-
cular pump failure, and congenital anomalies are
much less common causes. In addition, 85%–90%
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