Internal Coil Packing of an Amplatzer Vascular Plug after Incomplete Occlusion of the Afferent Vessel of a Splenic Artery Aneurysm

Immediate Percutaneous Treatment of Aortic Root Rupture During Transcatheter Aortic Valve Implantation

This case shows the combination of two percutaneous techniques to treat an aortic root rupture during transcatheter aortic valve implantation. The patient was discharged at home and no cardiovascular events occurred at 12 months of follow up.

Feasibility of the Glue-in-Plug Technique Using a Novel Liquid Embolic Material in a Swine Model

PURPOSE

To evaluate the feasibility of the glue-in-plug (GIP) technique using n-butyl-2-cyanoacrylate‒Lipiodol (NL)-iopamidol (NLI) for short-segment embolization in swine.

MATERIALS AND METHODS

The renal arteries, left external iliac artery, subclavian arteries, and common carotid arteries were each embolized in 4 swine using the GIP technique under general anesthesia. First, a type I Amplatzer vascular plug (AVP) (1-2 times the target vessel diameter) was deployed in the target artery. Next, the AVP was filled with NL mixture prepared at a ratio of 1:2 (NL12) (n = 11) or with NLI mixture prepared at a ratio of 2:3:1 (NLI231) (n = 11). Angiography was performed before, immediately after, and 1 hour after embolization to assess embolization and migration of the embolic materials. The embolized arteries were also evaluated histopathologically.

RESULTS

The migration distance of the embolic material beyond the plug tip was significantly shorter in the NLI231 group than in the NL12 group immediately after embolization (6.5 mm ± 4.5 vs 1.0 mm ± 1.8, P = .0024) and 1 hour after embolization (8.4 mm ± 5.6 vs 1.0 mm ± 1.8, P = .0013). Angiography revealed no sign of recanalization of the target vessels in any artery in either group. Mild inflammatory cell infiltration was observed around the arterial wall at the embolization site in all arteries in both groups.

CONCLUSIONS

The GIP technique using NLI231 may be a feasible procedure for short-segment embolization based on these short-term results.

Usefulness of preoperative simulation with patient-specific hollow vascular models for high-flow renal arteriovenous fistula embolization using a preloading coil-in-plug technique

The development of three-dimensional printers has facilitated the creation of patient-specific hollow vessel models. Preoperative simulations using these types of models have improved our ability to select appropriate devices and embolic materials before performing complex endovascular procedures. This report describes 2 cases of high-flow renal arteriovenous fistulas (r-AVFs) that were successfully treated via short-segment embolization using the preloading coil-in-plug (p-CIP) technique. To our knowledge, this is the first report of r-AVF being treated using the p-CIP technique. Our findings demonstrate that preoperative simulation has the potential to improve the safety and reliability of complex vascular embolization procedures.

Coil-In-Plug Technique Using the Amplatzer Vascular Plug II to Occlude a Portosystemic Shunt

INTRODUCTION

The family of Amplatzer Vascular Plugs (AVPs) is characterized by their precise deployment and high resistance to migration. However, a risk of recanalization of the embolized vessels has been reported. To augment the effectiveness of embolization, the coil-in-plug (CIP) technique was developed, exclusively using AVP I or IV. However, these plugs cannot be used for large vessels like portovenous shunt because of the size limitation. AVP II has a larger-sized model up to 22 mm. This article reports two cases of embolizing high-flow and large-caliber portosystemic shunts where the CIP technique with multilayer AVP II was effectively employed.

MATERIALS AND METHODS

The CIP technique using AVP II was utilized for one case with a portocaval shunt and another with a splenorenal shunt. CIP was established with wire penetration through the multilayer meshes, followed by a microcatheter insertion. After the microcatheter was positioned in the central lobe, the internal space was embolized tightly using pushable or detachable coils.

RESULTS

A use of guidewire with a high tip load enabled an establishment of CIP and complete occlusion of the target vessels immediately without migration of the embolic devices in both cases. The symptom of encephalopathy improved after the procedure in both the case of the portocaval and the splenorenal shunt.

CONCLUSION

The CIP technique with the AVP II was safe and effective to achieve complete occlusion of the large-caliber portosystemic shunts.

Clinical Utility of Coil in Plug Method (CIP) for Internal Iliac Artery Embolization during Endovascular Aortic Aneurysm Repair

Objective: To evaluate the clinical utility of the coil in plug (CIP) method in internal iliac artery (IIA) embolization during endovascular aortic aneurysm repair (EVAR) compared to conventional coil embolization (CCE).

Material and Methods: From July to December 2018, 10 patients who underwent IIA embolization during EVAR were divided into CIP (n=5) and CCE (n=5) groups. In the CIP technique, the AVP-1 with a size more than 30%–50% of that of the embolized IIA diameter was used. The AVP-1 was deployed in the IIA. Before detachment of the AVP-1, a 2.2-F micro catheter was inserted through the 6-F delivery guiding sheath, and entered the plug. The AVP-1 was then packed with hydrogel micro coils.

We compared number of coils used, embolization length, embolization time, volume embolization ratio, and embolic material cost between the groups.

Results: The CIP method achieved shorter embolization length with fewer coils used compared to CCE. The CIP method decreased the cost of total embolic materials.

Conclusion: The CIP method can achieve shorter embolization length with fewer coils used compared to CCE.

Elective Embolization of Splenic Artery Aneurysms with an Ethylene Vinyl Alcohol Copolymer Agent (Squid) and Detachable Coils

PURPOSE

To report the safety and efficacy of the embolization of splenic artery aneurysms (SAAs) with coils plus ethylene vinyl alcohol copolymer (EVOH) agent.

MATERIALS AND METHODS

A single-center retrospective study was conducted from 2016 to 2019 to collect SAAs. Twelve asymptomatic patients (mean age, 59 years) with 15 SAAs (mean size, 23.6 mm; size range, 15-40 mm) were treated with embolization. Embolization was performed with EVOH (Squid 8/34) and fibered detachable coils. Transfemoral embolization was performed with a microcatheter to achieve a splenic artery occlusion embolizing the SAA and its efferent and afferent branches. Follow-up was based on color Doppler ultrasound at 24 hours and on computed tomography (CT) angiography at 1 (n = 12) and 6 months (n = 12) after embolization. Mean number of coils and Squid vials used for each patient, major/minor complications, technical success, 30-day clinical success, cases of revascularization/reintervention, and mortality were assessed. Technical success was defined as complete exclusion of the aneurysmal segment and cessation of blood flow into the sac. Clinical success at 1 month was based on the absence of clinical symptoms and the exclusion of aneurysm revascularization on CT angiography.

RESULTS

The mean number of coils and Squid vials was 5.75 (standard deviation [SD], 1.58; range, 3-9) and 1.41 (SD, 0.49; range, 1-2), respectively. Both technical and 30-day clinical success were 100%, with no cases of aneurysm revascularization (CT angiography performed in all patients at 1 month and 6 months and in 3 patients at 24 months). No major complications or fatal events were recorded. In terms of minor complications, 2 cases of mild pancreatitis (transient amylases increase) and 1 case of focal splenic ischemia without clinical sequelae were recorded.

CONCLUSIONS

Embolization in SAAs using coils plus EVOH was safe and effective without SAA revascularization.

Internal coil packing method for the Amplatzer vascular plug 4

The Amplatzer vascular plugs (AVPs), including AVP 4, have excellent occlusion; however, insufficient embolization or recanalization may occasionally occur. This study aimed to evaluate the feasibility and effectiveness of internal coil packing method to insert microcoils into the AVP 4 using an experimental vascular model. The insertion of a 1.7 F microcatheter through the nitinol mesh of the AVP 4 was not possible. Only 0.010-inch electrolytic detachable microcoils could be inserted through catheter tips in contact with nitinol mesh. The internal coil packing of the AVP 4 may be accomplished by inserting 0.010-inch microcoils into the AVP 4 in cases of continued perfusion or recanalization with required short-segment embolization.