Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer.

OBJECTIVE: To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies. RESULTS: Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days). CONCLUSION: The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

Percutaneous embolization using a combination of liquid embolic agents for the treatment of a large disfiguring venous malformation.

A 25-year-old man with a venous malformation (VM) along the anterior and posterolateral aspects of the right chest wall presented with progressive enlargement of VM, chest wall pain, and physical disfigurement. Because of the complexity and size of the VM, a staged multidisciplinary team approach (ie, percutaneous embolization) followed by surgical resection and tissue-skin grafting was used. The percutaneous embolization was achieved with a combination of liquid embolic agents including n-butyl cyanoacrylate for the superficial cutaneous component and ethylene vinyl alcohol copolymer for the deeper subcutaneous component of the VM. Such a combination can achieve safe occlusion of the VM, facilitate surgical resection without blood loss, and contribute to a cosmetically desirable result.

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.

Pseudoaneurysm: a rare complication of distal transradial access in the anatomical snuffbox.

BACKGROUND: This report presents a case of distal radial artery pseudoaneurysm following cardiac catheterization and its successful endovascular management. Due to its novelty as a catheterization site, few to no reports exist regarding the complications associated with distal radial access. CASE PRESENTATION: A patient presented to the emergency department with severe wrist and hand swelling 48 h after successful cardiac catheterization via distal radial artery access. Angiography revealed a pseudoaneurysm which was embolized with Onyx™. Post intervention angiogram showed exclusion of the pseudoaneurysm and preservation of the left palmar arch vasculature. CONCLUSION: The case presented herein demonstrates a rare complication of distal radial access at the anatomical snuffbox.

Correction to: Radiofrequency wire 'power wire' recanalization of calcified chronically occluded inferior vena cava.

'In the published article (Salaskar et al. 2018) the statement under the subheading 'Consent for publication' is incorrect.

Successful embolization of a enterocutaneous fistula tract with Onyx 34 following low anterior resection for rectal cancer.

Enterocutaneous fistulas (ECFs) can be one of the complications found after surgical intervention for rectal cancer. Interventional modalities consisting of surgical, endoscopic, and radiological methods are often implemented to treat postoperative symptomatic complications. We present the case of 61-year-old Caucasian man who presented to us with a recent diagnosis of rectal cancer that had invaded the levators as well as anteriorly into the prostate, and who underwent low anterior resection with a diverting loop ileostomy. The patient was found to have a persistent presacral abscess due to an ECF tract. This case highlights the off-label use of ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx 34) to seal an ECF.

Radiofrequency wire 'power wire' recanalization of calcified chronically occluded inferior vena cava.

BACKGROUND: Radiofrequency (RF) wire recanalization of short segments of central venous obstruction has been considered safe; however its use for recanalization of long segments of inferior vena cava (IVC) has not been reported. CASE PRESENTATION: A 55-year-old female with recurrent massive hematemesis was found to have systemic venous upper esophageal varices on endoscopy and an extensive chronic IVC occlusion on CT. Using both a percutaneous transhepatic and transfemoral approach IVC recanalization was performed. A snare was advanced to the cavo-atrial junction via transhepatic venous access. From the groin utilizing RF wire steerable guide sheaths, endovascular reconstruction of the IVC was performed. Post recanalization venography demonstrated patent stented IVC and marked decrease in the intraabdominal-pelvic collaterals. No recurrence of hematemesis was noted. After 6 months, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft. CONCLUSIONS: Using appropriate techniques, Power wire recanalization of long occlusive segments of IVC can be safe and effective.

Endometrial Stromal Sarcoma Metastatic from the Uterus to the Inferior Vena Cava and Right Atrium.

Endometrial stromal sarcoma metastases usually occur within the pelvis and rarely involve the great vessels or the heart. We present the case of a 55-year-old woman who was referred for endovascular therapy to treat presumed thrombosis of the inferior vena cava. The suspected thrombus was recalcitrant to endovascular removal with use of an AngioVac venous drainage device. Results of an intraprocedural transvenous biopsy revealed the mass to be the intravascular extension of an endometrial stromal sarcoma. The patient underwent surgical excision of the tumor, and, shortly thereafter, a hysterectomy and salpingo-oophorectomy. This complex case highlights both the rarity of malignancy masquerading as caval thrombus and the importance of multispecialty collaboration.

Retrieval of TRAPEASE and OPTEASE Inferior Vena Cava Filters with Extended Dwell Times.

PURPOSE: To demonstrate that OPTEASE and TRAPEASE filters can be removed after dwell times greater than 60 days. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent an attempted removal of a TRAPEASE or OPTEASE filter with a greater than 60-day dwell time between 2009 and 2015 at a single institution. Eleven patients within that time span were identified, and 10 were included in the review. One patient was excluded from the study because the date of filter placement was unknown. RESULTS: All filters were successfully retrieved. The average dwell time for removed TRAPEASE filters was 1,273 days (range, 129-3,582 d), with a median of 492 days (n = 5). The average dwell time for OPTEASE filters was 977 days (range, 123-2,584 d), with a median of 661 days (n = 5). The average dwell time of all filters was 1,125 days (range, 123-3,582 d), with a median of 577 days (n = 10). All patients exhibited inferior vena cava (IVC) stenosis after filter retrieval. An IVC pseudoaneurysm was present following retrieval in one case and resolved. In one case, a fractured filter strut was left completely embedded in the caval wall. Two patients reported unilateral leg swelling on clinical follow-up, and the remainder reported no leg swelling or tightness. CONCLUSIONS: Initial experience suggests that TRAPEASE and OPTEASE filters can be removed after extended dwell times.

Acute, subacute, and long-term evaluation of a novel endovascular occlusion system in a large animal model.

OBJECTIVES: Endovascular occlusion of blood vessels represents a key component of interventional therapy. While coils are most commonly used, vessel occlusion is generally not achieved immediately and may necessitate a large number of devices. It has been suggested that endovascular plugs may overcome these limitations; however, immediate and durable occlusion remains a challenge with plugs as well. This study evaluates a newly designed endovascular occlusion system (EOS) METHODS: The EOS combines a nitinol coil with an impermeable membranous cap made of expanded polytetrafluoroethylene. The coil offers sufficient radial force to expand the membrane and minimize post-deployment migration. Fifteen test devices were deployed in the iliac (external and internal) and femoral arteries of five miniature swine, while two commercially available devices (platinum coils and a vascular plug) were used as controls in one miniswine. Angiography was performed 1, 5, and 10 minutes after device implantation. Follow-up angiography was obtained either on day 29 or day 61, prior to devices harvesting for histological evaluation and biocompatibility assessment. RESULTS: No clinical complications were observed in the animals throughout the study course. All test devices were deployed as intended, and produced complete and immediate vessel-occlusion. No recanalization or acute migration was observed within 10 minutes of deployment, whereas five test devices had migrated between 5 and 15 mm at follow-up angiography. Complete and durable vessel-occlusion without any sign of recanalization was observed in all EOS devices during the follow-up period. CONCLUSION: The EOS is a safe and reliable device resulting in immediate and durable vessel occlusion in the peripheral arterial circulation. While no device migration was observed in the pelvic area, it was observed with five test and one control devices in the vicinity of highly mobile articulations, leading to the conclusion that occlusion devices should not be placed within hypermobile areas such as the hip joint.

A new occlusion device: application of the ArtVentive endoluminal occlusion system (EOS)--first in human clinical trial.

PURPOSE: The purpose of this study was to determine the safety and efficacy of a new endoluminal occlusion device, ArtVentive endoluminal occlusion system (EOS), to occlude the spermatic vein in symptomatic males with varicoceles. METHODS: The ArtVentive EOS device has been developed for percutaneous, peripheral occlusion of the peripheral arterial and venous vasculature. The system is comprised of an implantable occlusion device and a delivery catheter. At present, there are two device sizes: (a) size 1 for target vessels ranging between 3.5 and 5.5 mm in diameter, and (b) size 2 for target vessels 5.5-8.5 mm in diameter. The treatment group included six adult males, ages 22-34 years. Nine target vessels were occluded. A total of 20 devices were implanted in six subjects. RESULTS: The acute occlusion rate at the end of the procedure was 100 % occurring in nine of nine vessels. The spermatic veins of all patients remained occluded on venography at 30 days follow-up. Pain scores related to varicoceles decreased in five of six patients. CONCLUSIONS: Although we recognize this study is limited, initial experience indicates that the ArtVentive EOS is a safe and effective new device for occlusion of vessels (varicoceles). The device has potential applications in other clinical conditions requiring occlusion of veins or arteries.

The endovascular occlusion system for safe and immediate peripheral vessel occlusion during vascular interventions.

Endovascular occlusion of blood vessels is an important part of interventional therapy concepts. Here, we evaluate the feasibility, procedural safety and efficacy of the novel endovascular occlusion system (EOS) in the arterial system in a porcine model. Thirteen devices were deployed in the iliac and femoral arteries (diameter: 4-5 mm) of five adult swine. Post-deployment angiography was performed at 1, 5 and 10 min and 6 h. All devices (n = 13) could be successfully delivered without any complications, such as dissection, perforation or rupture. The devices could be easily advanced to the target vessel segment, deployed at the intended target location and produced immediate and complete vessel occlusion which was confirmed to be maintained after 6 h. No leaks, recanalization or device migration was observed. In this pilot study, we demonstrate the feasibility, safety and efficacy of immediate vessel occlusion with the EOS device in the peripheral arterial system in a porcine animal model. Our data indicate that this novel device allows precise delivery without the occurrence of cardiovascular complications. Owing to its long-term safety and efficacy the EOS may represent a promising and effective alternative to currently available devices for vessel occlusion during vascular interventions.

Use of the 8-F angio-seal vascular closure device in large-caliber arteriotomies.

PURPOSE: To evaluate the feasibility and safety of using the 8-F Angio-Seal vascular closure device (VCD) to seal large-caliber (>8-F) access sites during percutaneous endovascular interventions. METHODS: A retrospective review was undertaken of 42 consecutive patients (34 men; mean age 67.8 years, range 36-94) undergoing percutaneous peripheral interventions with sheaths ranging from 9-F to 12-F and subsequent closure using 8-F Angio-Seal VCDs. Single-wall puncture (n = 48) of the common femoral artery was guided by ultrasound in 46 cases and palpation in 2. Forty procedures required therapeutic heparinization during the interventional procedure; protamine was administered in only 5. Per protocol, manual pressure was held for 15 minutes. Clinical and/or imaging follow-up was available in all cases within 3 months after the procedure. RESULTS: Immediate technical success was achieved in all cases, with hemostasis obtained within 5 minutes (no oozing or hematoma). The overall complication rate was 4.1% (2/48); one hematoma requiring surgical repair occurred 10 hours after VCD deployment. An asymptomatic pseudoaneurysm was discovered on follow-up imaging and was treated with ultrasound-guided thrombin injection with complete resolution. CONCLUSION: The use of the 8-F Angio-Seal VCD to close large-caliber arteriotomies ranging from 9-F to 12-F is feasible and safe, with a low complication rate.

Emergency endovascular stenting of the right iliac artery in a patient with secondary haemorrhage following transplant nephrectomy.

A patient presented with abdominal pain, hypotension and a retroperitoneal haematoma 5 days after transplant nephrectomy. Vascular injury sustained from transplant nephrectomy was repaired using endovascular techniques. Several known advantages to endovascular repair include: (1) intervention by a less invasive approach, (2) performance under local anaesthesia, (3) association with a shorter hospital stay and (4) reduction in morbidity and mortality. There were no infectious complications to the stent or the patient despite positive blood cultures obtained upon admission to the hospital. It was concluded that endovascular repair of an iliac artery used for kidney transplantation had favourable outcomes with respect to infection control and use of the vessel for future anastomosis.

Radiologic techniques and effectiveness of angiography to diagnose and treat acute upper gastrointestinal bleeding.

The use of catheter-based techniques to treat upper gastrointestinal hemorrhage has evolved considerably over the past few decades. At present, the state-of-the-art interventional suites provide optimal imaging. Coupled with advanced catheter technology, the two may be used to manage and treat the patient with acute upper gastrointestinal hemorrhage. This article summarizes these techniques and, when possible, compares them with other methods such as surgery and endoscopy. The specific role of transcatheter embolotherapy is highlighted, alongside an additional discussion on pharmacologic infusion of vasopressin.

Prophylactic inferior vena cava filters in high-risk bariatric surgery.

BACKGROUND: Bariatric patients are at significant risk for venous thromboembolism (VTE) and a subset may benefit from retrievable inferior vena cava filters (rIVCFs). Optimal VTE prophylaxis and a consensus on factors which make bariatric patients high risk have not been established. This study describes our experience with the use of rIVCFs in combination with chemoprophylaxis for high-risk bariatric surgery patients. METHODS: A retrospective review was performed of high-risk patients bariatric surgery patients. Patients with a hypercoaguable condition, prior history of VTE, body mass index (BMI) > 55 kg/m(2), and severe immobility were considered high risk. Patients underwent rIVCF placement and standard chemoprophylaxis. A venogram was performed at retrieval. RESULTS: Forty-four patients, age of 48 ± 12 years and BMI of 58.4 ± 9.4 kg/m(2) underwent gastric bypass with rIVCF placement. Follow-up was 204 days. One patient had a preoperative deep venous thrombosis (DVT). All patients received chemoprophylaxis and rIVCF placement. Indications for rIVCF were BMI (68%), prior VTE (30%), and immobility (2%). The operation was performed laparoscopically in all patients, and the mean operative time was 106.1 ± 21.6 min and length of stay was 3.1 ± 1.2 days. Postoperative venous duplex revealed two DVTs (5%). Retrieval was successful in 28 patients. No significant thrombus was found on venogram. Two minor complications of filter placement occurred. One mortality occurred due to MI, and no pulmonary emboli were clinically evident. CONCLUSIONS: rIVCFs in our cohort of high-risk bariatric surgery patients was associated with an acceptably low incidence of DVT (5%) and no clinically evident PE. Despite safe removal after long dwell times, previous data suggest that rIVCFs are associated with a higher incidence of VTE. Thus, filters, if placed, should be removed once the risk of VTE has passed. Larger multicenter studies are needed to truly identify long-term safety and efficacy of rIVCFs.

The safety and effectiveness of the retrievable option inferior vena cava filter: a United States prospective multicenter clinical study.

PURPOSE: To evaluate the safety and effectiveness of the retrievable Option inferior vena cava (IVC) filter in patients at risk for pulmonary embolism (PE). MATERIALS AND METHODS: This was a prospective, multicenter, single-arm clinical trial. Subjects (N = 100) underwent implantation of the IVC filter and were followed for 180 days; subjects whose filters were later removed were followed for 30 days thereafter. The primary objective was to determine whether the one-sided lower limit of the 95% CI for the observed clinical success rate was at least 80%. Clinical success was defined as technical success (deployment of the filter such that it was judged suitable for mechanical protection from PE) without subsequent PE, significant filter migration or embolization, symptomatic caval thrombosis, or other complications. RESULTS: Technical success was achieved in 100% of subjects. There were eight cases of recurrent PE, two cases of filter migration (23 mm), and three cases of symptomatic caval occlusion/thrombosis (one in a subject who also experienced filter migration). No filter embolization or fracture occurred. Clinical success was achieved in 88% of subjects; the one-sided lower limit of the 95% CI was 81%. Retrieval was successful at a mean of 67.1 days after implantation (range, 1-175 d) for 36 of 39 subjects (92.3%). All deaths (n = 17) and deep vein thromboses (n = 18) were judged to have resulted from preexisting or intercurrent illnesses or interventions and unrelated to the filter device; all deaths were judged to be unrelated to PE. CONCLUSIONS: Placement and retrieval of the Option IVC filter were performed safely and with high rates of clinical success.

Technical success and safety of retrieval of the G2 filter in a prospective, multicenter study.

PURPOSE: To assess the technical success and safety for retrieval of the G2 filter. MATERIALS AND METHODS: The authors performed a prospective, multicenter study of 100 patients with temporary indication for caval interruption. Patients were enrolled consecutively between December 2005 and July 2006. There were 67 men and 33 women with a mean age of 52.1 years (range, 19-82 years). Indications for filter placement were trauma (n = 56), perioperative risk (n = 16), and medical indications (n = 28). Forty-two patients had venous thromboembolism at filter placement. Fifty-eight filters were placed prophylactically. RESULTS: Retrieval was attempted in 61 patients. Fifty-eight of the 61 filters (95%) were successfully retrieved after a mean dwell time of 140 days (range, 5-300 days). In all failed retrievals, the filter tip was against the caval wall. There was no difference in dwell times between successful and unsuccessful retrievals. Although there were no cases of cranial migration, caudal migrations were observed in 12% of cases (10 of 85 patients with a complete data set). Other device-related complications included filter fracture (1/85, 1.2%), filter tilt of more than 15 degrees (15/85, 18%), and leg penetration (16/61, 26%). The recurrent pulmonary embolism (PE) rate was 2%, with no PE in the 30-day period after filter retrieval. CONCLUSIONS: Retrieval of the Recovery G2 filter was safe and successful in most patients. Caudal migration was observed as an unexpected phenomenon.