Percutaneous Transhepatic Embolization of Bleeding Rectal Varices Using A New Embolic And Sclerotic Mixture Augmented By Amplatzer Vascular Plug 2.

We report a case of 59-year-old female with non-alcoholic-steato-hepatitis (NASH) induced cirrhosis, who presented with hematochezia. The patient had a history of bleeding esophageal varices treated with endoscopic variceal ligation (EVL). Colonoscopy showed large rectal varices which were the source of her lower gastrointestinal bleeding (LGIB). Since endoscopic treatment for LGIB are limited, and because the patient had portal vein thrombosis which contraindicated transjugular intrahepatic portosystemic shunt (TIPS), we performed percutaneous transhepatic embolization of her rectal varices using a new mixture of embolic and sclerotic agents, followed by Amplatzer plug 2 (AVP 2). To our knowledge, the use of this new mixture with the AVP 2 in the rectal varices treatment has not been previously published in literature. Our case provides an alternative treatment modality that can be used for rectal varices treatment, when TIPS and endoscopic management fails or is contraindicated.

Traumatic complex splenic arteriovenous fistula causing prehepatic portal hypertension and variceal bleeding: the importance of the diagnosis for the endovascular treatment approach.

We report a case of a 68-year-old female patient presenting with portal hypertension and variceal bleeding in the absence of any liver disease. After performing a computed tomography angiogram, the cause of her condition was identified to be a splenic arteriovenous fistula (SAVF). After confirming the findings with angiography, we opted to treat the condition with coil embolization as an alternative to a more invasive surgical treatment. Coil embolization of the SAVF was performed successfully resulting in the improvement of the patient's variceal congestion. Our case highlights the importance of identifying SAVF as a potentially curable cause of variceal bleeding in the absence of liver disease. Seeking this diagnosis is of utmost importance since it completely changes the endovascular approach and management of these patients with variceal bleeding. We describe a minimally invasive endovascular technique for treatment of these critically ill patients.

Endovascular management of nonvariceal upper gastrointestinal hemorrhage.

Upper gastrointestinal bleeding (UGIB) remains a frequent presentation in the emergency department. There are several causes of UGIB, which can be generally classified into variceal and nonvariceal bleeding. Although most cases of nonvariceal UGIB spontaneously resolve or respond to medical management and/or endoscopic treatment, transcatheter arterial embolization (TAE) remains an important available tool in the emergency evaluation and management of nonvariceal UGIB. In this article, we will discuss the current strategies for rendering a specific diagnosis of nonvariceal UGIB, and we will focus on the various TAE techniques for its management. We will also provide an algorithm for the diagnostic work-up of these patients. The majority of patients with nonvariceal UGIB that is refractory to endoscopic treatment is successfully treated with minimally invasive TAE and can avoid undergoing surgery.

Guide wire entrapment in a vena cava filter: techniques for dislodgement.

Entrapment of a central venous catheter (CVC) guide wire in an inferior vena cava (IVC) filter is a rare, but reported complication during CVC placement. With the increasing use of IVC filters, this number will most likely continue to grow. The consequences of this complication can be serious, as continued traction upon the guide wire may result in filter dislodgement and migration, filter fracture, or injury to the IVC. In this article, we review the various preferred techniques reported in the literature for removal of the entrapped guide wire in particular situations, along with their indications, advantages, and disadvantages. We present simple useful recommendations to prevent this complication.

Unusual appearance and presentation of supratentorial subependymoma in an adult patient.

We report a case of a large, heterogeneously enhancing, pathologically proven, supratentorial subependymoma in a 31-year-old male patient presenting with headache, nausea and vomiting as well as gait disturbances. Although most supratentorial subependymomas have distinctive MR features, our case demonstrated imaging findings that made it indistinguishable from other more aggressive malignant supratentorial intraventricular lesions. It is of paramount importance to consider supratentorial subependymomas in the differential diagnosis of supratentorial lesions, even if their radiological features were atypical.

Repositioning of surgically placed peritoneovenous shunt catheter by forming "in situ" loop snare: case report and review of literature.

We describe a technique that allows repositioning of malfunctioning peritoneovenous shunt (PVS) catheters. We report a 67-year-old female with refractory ascites, who presented with malfunctioning PVS. The catheter tip was outside the superior vena cava (SVC), possibly in a small mediastinal vein, which makes its tip inaccessible to regular snares and retrieval devices. We used "in situ" loop snare technique to reposition the tip of the catheter into the inferior vena cava (IVC). In situ loop snare technique can be used to reposition malfunctioning PVS catheters caused by a kink or by malposition of its tip. The technique avoids surgical or interventional replacement of these catheters. This technique can be also used for retrieval of foreign body fragments that have no free ends and, therefore, cannot be captured by a snare or other retrieval devices.

Treatment of acute inferior vena cava and iliac vein thrombosis with pharmacomechanical thrombectomy using simultaneously operating "kissing" Trellis-8 thrombolysis catheters.

PURPOSE: To present a new endovascular technique for treating acute large thrombus burden in the iliocaval venous system. TECHNIQUE: This method is demonstrated in a 62-year-old man with end-stage renal disease on hemodialysis who had a nonfunctioning right femoral dialysis catheter that was placed 3 month earlier. After catheter removal, venography demonstrated significant thrombus in the inferior vena cava (IVC) and both iliac veins. The patient was treated successfully using two simultaneously operating Trellis-8 thrombolysis catheters placed side-by-side in the IVC and both iliac veins in a "kissing" configuration. CONCLUSION: This technique was able to effectively debulk acute large thrombus burden in the iliocaval system in a single session and preserve the patient's available hemodialysis access. The technique has the potential to minimize morbidity, duration of hospital stay, and overall cost of treatment.

Embolization of bleeding duodenal ulcer using Amplatzer vascular plug II and hydrogel coils: case report.

PURPOSE: To present a case of upper gastrointestinal bleeding (UGIB) that was treated with percutaneous endovascular embolization using Amplatzer vascular plug and hydrogel coils after failed endoscopic treatment. CASE REPORT: A 78-year-old male was referred for endovascular treatment of massive recurrent UGIB from a duodenal ulcer. Attempts at endoscopic treatment were unsuccessful. Based on our knowledge of the site of the bleeder in the duodenum from prior endoscopy, we decided to empirically embolize the gastroduodenal artery (GDA) and the right gastroepiploic artery using a combination of coils (Azur peripheral hydrocoil; Terumo Medical Corporation, Somerset, New Jersey) and Amplatzer vascular plug II (AVP II; AGA Medical, Plymouth, Minnesota). CONCLUSION: We present this case of UGIB where effective, rapid, precise, and controlled embolization of the GDA was achieved using AVP II device in combination with coils. To our knowledge, the use of AVP II in embolization of GDA for treatment of emergent UGIB has not been described in the literature.

Occlusion time for Amplatzer vascular plug in the management of pulmonary arteriovenous malformations.

OBJECTIVE: The occlusion time, that is, the interval between device deployment and complete occlusion of the vessel, associated with the use of embolic devices influences the risk of embolic complications caused by small clots that can form over the surface of a device and break away. The purpose of our study was to determine the time for an Amplatzer vascular plug to bring about percutaneous transcatheter occlusion of a pulmonary arteriovenous malformation (PAVM). MATERIALS AND METHODS: We retrospectively studied the occlusion times of Amplatzer vascular plugs in the management of 12 PAVMs. We recorded the number, location, type (simple or complex), and diameter and number of feeding arteries of PAVMs; the number and size of devices needed to occlude each PAVM; and the occlusion time for each PAVM. The occlusion time is the time interval from device placement to complete occlusion of the PAVM. Occlusion time was determined by recording the time between acquisition of the first angiographic image after deployment of the device and the angiogram that showed total occlusion of the PAVM. The relevant literature on the subject was reviewed. RESULTS: All PAVMs managed were supplied by a single feeding artery. The average diameter of the feeding arteries was 4.8 mm (range, 3.0-11.2 mm). All PAVMs were occluded by deployment of a single Amplatzer vascular plug. Vascular plug sizes ranged from 4 to 16 mm. The mean occlusion time was 3 minutes 20 seconds (range, 1 minute 49 seconds-5 minutes 16 seconds). There were no immediate complications, including air embolism and thromboembolism. CONCLUSION: The occlusion time determined in our study and the need to place only one Amplatzer vascular plug in each feeding artery to achieve complete occlusion in most cases suggest that the device is safe for management of PAVM with no increased risk of systemic embolization. The use of the Amplatzer vascular plug for PAVM embolization is a relatively recent development. Long-term follow-up studies are needed to assess recanalization rates, radiation exposure rates, and risk of device migration.