Enhancing precision in vascular embolization: evaluating the effectiveness of the intentional early detachment technique with detachable coils in complex cases

BACKGROUND

This study aimed to assess the effectiveness and versatility of an intentional early detachment technique with detachable coils in addressing challenging vascular embolization scenarios. This novel approach aims to provide an alternative method for achieving precise coil placement when standard methods of detachable coil placement are ineffective owing to vascular anatomy or limited available equipment.

MATERIALS AND METHODS

This retrospective study included 11 patients (nine males and two females; median age, 77 years) who underwent embolization procedures between October 2021 and December 2023 using the intentional early detachment technique through 1.6-Fr or 1.3-Fr microcatheters. In this technique, detachable coils were intentionally detached within the microcatheter and placed through saline flushing. The technique's technical success, complications, and clinical success were evaluated.

RESULTS

The technique was applied in three distinct scenarios: tortuous vascular anatomy (four cases), inadequate system backup (three cases), and 1.3-Fr microcatheter use (four cases). The technical and clinical success rates were 100%. No complications were observed, and no cases of coil migration or malpositioning.

CONCLUSION

The intentional early detachment technique is valuable for interventional radiologists and offers a solution for challenging vascular embolization scenarios. Its application is limited to specific circumstances; however, it can significantly enhance coil placement in complex cases, thereby contributing to improved patient care.

Management of pseudoaneurysms of the internal maxillary artery derived from orthognathic surgery based on one case

PURPOSE

The purpose of this article is to highlight the risk of pseudoaneurysms formation after orthognathic surgery, their clinical features and management.

METHODS

A case report of a 24-year-old man who suffered a pseudoaneurysm of the internal maxillary artery after sagittal osteotomy during orthognathic is reported. After three bleeding episodes, a pseudoaneurysm was diagnosed with a computed tomography angiogram (CTA) and treated with an embolization of the internal maxillary artery with polyvinyl alcohol (PVA) successfully.

RESULTS

Pseudoaneurysms derived from the external carotid artery are an uncommon complication of orthognathic surgery, especially related to sagittal osteotomy instead of LeFort I osteotomy.

CONCLUSION

Pseudoaneurysms derived from external carotid artery branches must be suspected when patients show multiple episodes of bleeding (epistaxis or through the surgical approach) within the first two weeks after orthognathic surgery. If so, vascular CT or angiography should be performed to rule out the presence of vascular injuries. In case a pseudoaneurysm is identified, vascular embolization with N-butyl-cyanoacrylate seems to be the best treatment if available. If this treatment is not available or bleeding cannot be controlled, surgical ligature of the injured vessel is a valid treatment.

Hemorrhagic shock due to ruptured lower limb vascular malformation in a neurofibromatosis type 1 patient: A case report

BACKGROUND

Neurofibromatosis type 1 (NF-1) is a common autosomal dominant genetic disorder. It is characterized by café-au-lait spots and cutaneous neurofibromas. Although NF-1 typically involves the skin, nerves, bones, and eyes, vascular manifestation in the form of devastating hemorrhage can occur rarely.

CASE SUMMARY

We present the case of a 47-year-old female with NF-1 who had a ruptured right lower limb arterial malformation. She presented with sudden right lower limb swelling for two hours and symptoms of hemorrhagic shock on admission. The physical examination revealed a right lower limb presenting as elephantiasis and visible dark-brown pigmentation over a large area. Computed tomography angiography showed right lower limb arteriovenous malformation. Therefore, the patient underwent emergency right lower limb digital subtraction angiography (DSA) and vascular embolization after blood transfusions. However, after DSA, vascular embolization, and repeated blood transfusions, the anemia and right lower limb swelling and tenderness did not improve. As a result, the patient underwent right lower extremity above-knee amputation. After amputation, the patient's hemoglobin level improved significantly without blood transfusion, and she was discharged from the hospital after the incision healed. Postoperative pathological examination suggested neurogenic tumors. No other complications had occurred 1-year follow-up.

CONCLUSION

Vascular malformation and rupture are fatal complications of NF-1. Embolization may not provide complete relief, the patient might need to undergo neurofibroma resection or amputation.

Early vascular embolization of large orbital and periorbital infantile capillary hemangiomas; A case report

Purpose

Infantile hemangiomas (IH) are the most common benign vascular tumors in childhood. Although they tend to have a benign nature, some hemangiomas may be complicated with astigmatism or deprivation amblyopia. We report a unique case of using an interventional radiological vascular embolization treatment modality for the early management of amblyogenic large right orbital and periorbital infantile capillary hemangiomas.

Observations

After the confirmation of the diagnosis using a magnetic resonance imaging (MRI) of the brain and orbit, and an initial trial of systemic propranolol, an early interventional radiological vascular embolization was done. This was combined with the use of a tapering systemic corticosteroid. The functional and cosmetic outcomes were satisfactory.

Conclusions and Importance

The use of arterial embolization is a promising modality of treatment as a possible alternative or adjunct to medical and surgical treatment cases of IH. To the authors’ knowledge, this is one of the rare cases reported in the ophthalmic literature addressing the use of this technique for early management of orbital and periorbital capillary hemangiomas.

Spontaneous rupture of the ovarian vein in association with nutcracker syndrome: a case report

Background

Nutcracker syndrome is a condition in which the left renal vein is pinched between the abdominal aorta and the superior mesenteric artery, resulting in an increase in renal vein pressure and certain symptoms. We report a very rare case of retroperitoneal hematoma caused by the rupture of varicose veins of the left ovary.

Case presentation

A 77-year-old Japanese woman, para 7, experienced sudden left lower abdominal pain. She had no history of trauma or treatment complications. Computed tomography revealed a left retroperitoneal hematoma, but her abdominal pain subsided quickly; thus, urgent treatment was not required. We then scheduled her for an assessment regarding the cause of her bleeding. However, 6 days after the pain onset, abdominal pain symptoms recurred, confirming hematoma regrowth. Magnetic resonance imaging and three-dimensional computed tomography revealed an abnormal vascular network from the left side of the uterus to the left adnexa. Subsequent angiography revealed that the retroperitoneal bleeding originated from rupture of the distended left ovarian vein, which caused blood reflux from the left renal vein to the left ovarian vein. Although angiography confirmed a passage between the left renal vein and inferior vena cava, computed tomography showed obvious stenosis in the left renal vein. In accordance with these findings, we diagnosed the cause of the distention and rupture of the left ovarian vein as nutcracker syndrome. She underwent embolization of the left ovarian vein as hemostasis treatment, and had a good course thereafter.

Conclusions

This is the first report of a spontaneous rupture of the left ovarian vein caused by nutcracker syndrome. Nutcracker syndrome is not yet well known to clinicians and should be considered as part of the differential diagnosis when an abnormal vascular network in the pelvis is found.

Temperature-responsive biodegradable injectable polymers with tissue adhesive properties

Injectable polymers (IPs) exhibiting in situ hydrogel formation have attracted attention as vascular embolization and postoperative adhesion prevention materials. While utilizing hydrogels for such purposes, it is essential to ensure that they have appropriate and controllable tissue adhesion property, as it is crucial for them to not detach from their deposited location in the blood vessel or abdominal cavity. Additionally, it is important to maintain gel state in vivo for the desired period at such locations, where large amounts of body fluid exist. We had previously reported on a biodegradable IP system exhibiting temperature-responsive gelation and subsequent covalent cross-link formation. We had utilized triblock copolymers of aliphatic polyester and poly(ethylene glycol) (tri-PCGs) and its derivative containing acrylate group at the termini (tri-PCG-Acryl), exhibiting a longer and more controllable duration time of the gel state. In this study, the introduction of aldehyde groups by the addition of aldehyde-modified Pluronic (PL-CHO) was performed for conferring controllable and appropriate tissue adhesive properties on these IP systems. The IP systems containing PL-CHO, which were not covalently incorporated into the hydrogel network, exhibited tissue adhesive properties through Schiff base formation. The adhesion strength could be controlled by the amount of PL-CHO added. The IP system showed good vascular embolization performance and pressure resistance in the blood vessels. The IP hydrogel remained at the administration site in the abdominal space for 2 days and displayed effective adhesion prevention performance. STATEMENT OF SIGNIFICANCE: Injectable polymers (IPs), which exhibit in situ hydrogel formation, are expected to be utilized as vascular embolization and postoperative adhesion prevention materials. The tissue adhesion properties of hydrogels are important for such applications. We succeeded in conferring tissue adhesion properties onto a previously reported IP system by mixing it with Pluronic modified with aldehyde groups (PL-CHO). The aldehyde groups allowed for the formation of Schiff bases at the tissue surfaces. The tissue adhesion property could be conveniently controlled by altering the amount of PL-CHO. We revealed that the in vitro embolization properties of IPs in blood vessels could be substantially improved by mixing with PL-CHO. The IP system containing PL-CHO also exhibited good in vivo performance for postoperative adhesion prevention.

Retropharyngeal hematoma presenting airway obstruction: A case report

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Falling patients on warfarin can result in a late-onset airway obstruction.

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Retropharyngeal hematoma patients are with difficult orotracheal intubation.

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Arterial embolization may be effective for hemostasis of retropharyngeal hematoma.

Introduction

Blunt neck trauma patients can suffer from an airway emergency and are necessary to careful observation.

Presentation of case

A 79-year-old man under anticoagulation therapy presented to our hospital three hours after a fall. Shortly after arrival, he developed dyspnea. Oral intubation was attempted, but with no success; therefore, an emergency tracheotomy was performed. Contrast-enhanced computed tomography (CT) and subsequent angiography revealed active bleeding from a branch of the right ascending cervical artery. Subsequently, the right thyrocervical trunk, which is upstream from the ascending cervical artery, was embolized and hemostasis was achieved. He was discharged 52 days after the emergency admission.

Discussion

This is the first case report of an ascending cervical artery injury due to blunt trauma that resulted in an airway emergency. Contrast-enhanced CT and cervical angiography are useful for confirming the area of injury and size of the hematoma. Half of patients with respiratory distress accompanied by a cervical spine injury require definitive airway management within five hours of the injury and all by 24 h. Neck trauma can lead to fatal airway obstruction and careful monitoring is warranted to detect any signs of impeding respiratory obstruction.

Conclusion

All emergency physicians need to keep their airway management skills updated in order to perform reliably and rapidly in difficult and urgent situations.

Arteriovenous Fistula Inside Cervical Spinal Canal Associated with Neurofibromatosis Type 1

BACKGROUND

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease caused by mutation on chromosome 17, which affects the skin, vascular system, nervous system, and skeleton system. Arteriovenous fistula (AVF) is one of the recognized complications of NF-1.

CASE DESCRIPTION

We report a case of a 33-year-old woman with NF-1 with cervical spine AVF inside the cervical spinal canal who presented with progressive spinal cord compression which was abnormal. After sufficient preparation, the patient underwent vascular embolization, and then symptoms of spinal cord compression significantly improved.

CONCLUSIONS

This report reminds readers of the possibility of AVF if there is a space-occupying lesion inside the cervical spinal canal and to do computed tomography angiography examination when necessary.

Durable Benefit of Particle Occlusion of Systemic to Pulmonary Collaterals in Select Patients After Superior Cavopulmonary Connection

Systemic to pulmonary arterial collaterals (SPC) are commonly found in patients undergoing staged operative palliation for single ventricle heart disease. Occlusion of SPC as part of pre-Fontan catheterization has been shown to improve hemodynamics acutely. Anecdotally, the effect of this intervention appears to be transient, and to our knowledge there is no data supporting its durability in these patients. Between 1/1/2016 and 5/1/2017, 24 children underwent Glenn operations at our institution. Of these, 3 patients had signs and symptoms deteriorating clinical status suggestive of volume overload in the period between their Glenn operation and Fontan completion, prompting heart catheterization. SPC were occluded with a combination of polyvinyl alcohol embolization particles, and in some cases coils or vascular plugs. Clinical course and data from echocardiograms and serial catheterizations are presented. SPC occlusion was performed over 6 procedures in 3 subjects with technical success in each case. Hemodynamic evaluation was repeated in 2/3 patients with improvement in collateral burden and hemodynamics in both cases. One patient previously thought to be unsuitable for Fontan completion improved sufficiently to undergo late Fontan completion, which was ultimately successful. In all patients, there was improvement in clinical status. In patients with severe SPC collateral durable benefit was seen, suggesting that in certain cases intervention on SPC remote from Fontan completion may have clinical benefit.

Polymerization kinetics of a mixture of Lipiodol and Glubran 2 cyanoacrylate glue upon contact with a proteinaceous solution

The Glubran 2 cyanoacrylate glue is a liquid embolic agent used to block blood vessels endovascularly. Typically mixed with an iodized oil (Lipiodol) for visualization under X-ray, it polymerizes when in contact with blood and tissues owing to the presence of ions and proteins. The objective of the study is to determine the influence of plasma proteins in the polymerization reaction. A triggering solution containing bovine serum albumin (BSA) and the main blood ions is used as a model of plasma. The polymerization kinetics of Glubran 2-Lipiodol mixtures is measured upon aspiration in a capillary tube and contact with the proteinaceous solution. Having varied the glue and protein concentrations, we show that glue-Lipiodol mixtures with concentrations larger or equal to 25% polymerize when put in contact with an ionic solution containing at least 4% of BSA. The reaction is decomposed into two phases: a fast zwitterionic polymerization induced by the BSA molecules followed by a slower polymerization phase. The reaction speed and extent of the solidification region mostly depend on the glue concentration. The time for the glue solution to polymerize over a 1mm thickness varies from 5s for pure glue to about 1min for a 50% glue concentration, and 10min for a 25% glue mixture. It is the first time that the kinetics of the two polymerization reactions is quantified for Glubran 2, which will provide the information needed by interventional radiologists to optimize the planning of endovascular glue injection.

Polymerization kinetics of n-butyl cyanoacrylate glues used for vascular embolization

Vascular embolization is a minimally invasive treatment used for the management of vascular malformations and tumors. It is carried out under X-ray by navigating a microcatheter into the targeted blood vessel, through which embolic agents are delivered to occlude the vessels. Cyanoacrylate liquid glues have been widely used for vascular embolization owing to their low viscosity, rapid polymerization/solidification rate, good penetration ability and low tissue toxicity. The objective of this study is to quantitatively investigate the physical properties of two n-butyl cyanoacrylate (nBCA) glues (Glubran 2 and Histoacryl) mixed with an iodized oil (Lipiodol) at various concentrations. We show that an homogeneous solution results from the mixing of the glue and Lipiodol, and that the viscosity, density and interfacial tension of the mixture increase with the proportion in Lipiodol. We have designed a new experimental setup to systemically characterize the polymerization kinetics of a glue mixture upon contact with an ionic solution. We observe that the whole polymerization process includes two phases: an interfacial polymerization that takes place at the interface as soon as the two liquids are in contact with a characteristic time scale of the order of the minute; a volumetric polymerization during which a reaction front propagates within the mixture bulk with a characteristic time scale of the order of tens of minutes. The polymerization rate, front propagation speed and volume reduction increase with the glue concentrations. It is the first time that such comprehensive results are obtained on liquid embolic agents.

Vascular intervention combined with surgery for the management of huge asymptomatic pheochromocytoma: A report of one case

Asymptomatic pheochromocytoma accounts for about 10%-17% of cases of adrenal gland pheochromocytoma. Due to the lack of specific clinical symptoms and signs, asymptomatic pheochromocytoma is often difficult to diagnose. As it often has a rich blood supply and blood supply source is extremely irregular, surgical excision is challenging. A patient was admitted to our hospital due to repeated right epigastric pain and abdominal distension for 2 years and aggravation for 7 days. A preoperative diagnosis of right upper quadrant abdominal huge tumor was made. He underwent vascular intervention and surgical excision, and postoperative pathologic analysis suggested pheochromocytoma.