Embolization of Trauma-Associated Pelvic Hemorrhage: Feasibility of Super-Selective Catheterization in Heavily Injured Patients as a Damage Control for Life-Threatening Pelvic Bleeding

박준영,임남열,김재규,김형욱,강양준,정혜두,김슬기,윤웅 대한영상의학회 2016 대한영상의학회지 Vol.74 No.4

Purpose: To determine the efficacy of embolization with super-selective catheterization of the internal iliac arterial branches to treat heavily injured trauma patients with pelvic arterial bleeding. Materials and Methods: A retrospective analysis was performed using the medical records of 37 patients who underwent trans-arterial embolization for trauma-associated pelvic arterial hemorrhage in a regional trauma center between July 2010 and July 2013. In each patient, hemodynamic stability, embolization level, elapsed time for trans-arterial embolization, clinical outcome and embolization-related complications were evaluated. Comparison of elapsed time, and presence of complication was done according to embolization level. Results: Transarterial embolization was conducted in 37 patients. Hemodynamic stability of each patient was classified into hemodynamic stable (n = 9), and unstable (n = 28). Twenty-nine of 37 patients underwent embolization after super-selective catheterization of more than 2nd order branch of internal iliac artery with a microcatheter, and 8 patients underwent proximal internal iliac artery embolization without super-selective catheterization. The mean elapsed procedure time for super-selective embolization (34.76 ± 20.0 minutes) was not significantly longer than proximal internal iliac artery embolization (33.87 ± 16.73 minutes, p = 0.215). Conclusion: Pelvic arterial embolization with super-selective catheterization is a safe and feasible treatment for heavily injured patients with trauma-associated pelvic arterial bleeding.

Selective Embolization for Post-Endoscopic Sphincterotomy Bleeding: Technical Aspects and Clinical Efficacy

소영호,최영호,정진욱,제환준,송순영,박재형 대한영상의학회 2012 Korean Journal of Radiology Vol.13 No.1

Objective: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. Materials and Methods: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. Results: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; ± 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. Conclusion: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding. Objective: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. Materials and Methods: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. Results: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; ± 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. Conclusion: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.

Surgical treatment of highly vascular intra-cranial meningioma and efficacy of pre-operative embolization : its clinical and histopathological findings

Lee, Sun-Il,Sim, Jae Hong 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.4

Introduction: Most meningiomas are begin and curable lesions. Therefore, the best of available treatment is complete surgical resection, Pre-operative embolization of highly vascular meningiomas should be an effcient technique for facilitating their surgical removal by decreasing blood loss, shortening surgical resection time and decreasing surgical complication and for the reducing tumor recurrence by producing necrosis at the site of dural attatchment although some controversy exists to the value of the embolization of convexity meningiomas. To evaluate the clinical efficacy and safety of pre-surgical devascularization of meningiomas, we reviewed the operative and histopathological findings which were subjected to pre-operative embolization. Materials and Methods: For the last 10 years, we have treated 245 meningiomas, of which 153 patients were operated by conventional microsurgical technique and 92 patients were treated by Gamma Knife radiosurgically. Among them, 35 meningiomas (12 men, 23 women) underwent superwent superselective embolization with 150∼250 microns PVA(polyvynil alcohol) particles. We compared the degree of surgical resectability between the group of patients in whom embolization was performed and the group not performed and analyzed the histopathological findings according to time interval after embolization to operation. Results: 25 cases(71%) were totally resected including dural attachment site without significant operative difficulties and intra-operative blood loss, post-operative complications. 8cases(23%) were subtotally resected. The histopathological findings included coagulative necrosis(54%), florid ischemic change, hyaline arteriosclerosis, many macrophage which contained PVA particles. However, vascular recanalization was not seen until 7 days after embolization. Conclusion: Pre-operative embolization of meningiomas should be done with the superselective technique whenever feasible and it is recommendableto operate within 7days after embolization significant operative difficulties and intra-operative blood loss, post-operative complications, 8cases(23%) were subtotally resected. The histopathological findings included coagulative necrosis(54%), florid ischemic change, hyaline arterioscleroses, many macrephage which contained PVA particles. However, vascular recanalization was not seen until 7 days after embolization. Conclusion: Pre-operative embolization of meningiomas should be done with the superselective technique whenever feasible and it is recommendableto operate within 7 days after embolization.

신손상 환자에서 혈관 색전술의 효용성

권영기 ( Young Kee Kwon ),장혁수 ( Hyuk Soo Chang ),김병훈 ( Byung Hoon Kim ),박철희 ( Choal Hee Park ),김천일 ( Chun Il Kim ) 대한외상학회 2010 大韓外傷學會誌 Vol.23 No.1

Purpose: High-grade (III, IV, V) renal injury may need interventional management. We investigated whether the selective embolization of the renal artery is effective for the treatment of major renal injury in comparison with emergency renal exploration. Methods: We retrospectively reviewed the medical and radiologic records of patients who underwent surgery or embolization for renal injury (Grade III, IV, V) between January 1990 and December 2007. We analyzed the change in treatment method before and after 2000, the blood pressure, the hemoglobin at the time of visit, the hospital days and the complications in patients who received surgery or embolization. Preserved renal functions of the embolized kidneys were identified by using enhanced CT. Results: Cases of surgery and embolization were 37 and 13, respectively: 5 and 4 in renal injury grade III, 17 and 6 in grade IV and 13 and 3 in grade V. Cases of surgery and embolization were 33 and 1 before 2000 and 2 and 12 after 2000, repectively: embolizations increased after 2000. No significant differences in mean diastolic pressure, hemoglobin, hospital days and complications existed between the surgery and the embolization groups (p>0.05). However, the transfusion volume was significantly smaller in the embolization group (p<0.05). One postoperative complication occurred in the surgery group. We identified the preserved renal functions of the embolized kidney by using enhanced CT. Conclusion: Embolization could be one treatment method for high-grade renal injury. Thus, we might suggest selective embolization a useful method for preserving the renal function in cases of high-grade renal injury. (J Korean Soc Traumatol 2010;23:16-20)

Trends in Utilization of Preoperative Embolization for Spinal Metastases: A Study of the National Inpatient Sample 2005–2017

Wahood Waseem,Alexander Alex Yohan,Yolcu Yagiz Ugur,Brinjikji Waleed,Kallmes David F.,Lanzino Giuseppe,Bydon Mohamad 대한신경중재치료의학회 2021 Neurointervention Vol.16 No.1

Purpose: While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database.Materials and Methods: The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization.Results: A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P<0.001). The majority of patients in the non-preoperative embolization cohort had a primary lung tumor (n=3,562, 31.24%). Additionally, patient comorbidities were similar among the 2 groups (P>0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P<0.001) in utilization per year.Conclusion: Utilization of preoperative embolization for spinal metastasis is increasing yearly, especially for patients with renal cancer, suggesting that surgeons may increasingly consider embolization before surgical resection for hypervascular tumors. Additionally, the literature has shown the intraoperative and postoperative benefits of this procedure.

Comparison of transarterial n-BCA and Onyx embolization of brain arteriovenous malformations: A single-center 18-year retrospective analysis

Behzadi Faraz,Heiferman Daniel M,Wozniak Amy,Africk Benjamin,Ballard Matthew,Chazaro Joshua,Zsigray Brandon,Reynolds Matthew,Anderson Douglas E,Joseph C Serrone 대한뇌혈관외과학회 2022 Journal of Cerebrovascular and Endovascular Neuros Vol.24 No.2

Objective: Brain arteriovenous malformations (AVM) are commonly treated with endovascular embolization. Due to the rapid evolution of endovascular technology and lack of consistent practice guidelines regarding AVM embolization, further study of AVM embolization outcomes is warranted.Methods: We conducted a retrospective review of AVMs embolized at a single center from 2002-2019. Patient demographics, AVM characteristics, intention of embolization, and angiographic and clinical outcome after embolization were recorded. We compared the embolization results of those treated with n-butyl cyanoacrylate (n-BCA) and Onyx.Results: Over an 18-year period at our institution, 30 (33%) of 92 AVMs were treated with embolization. n-BCA was used in 12 cases and Onyx in 18 cases. Eighty-seven pedicles were embolized over 47 embolization sessions. Fifty percent of AVMs treated with n-BCA underwent more than one embolization session compared to 22% when Onyx was used. The median total percent volume reduction in the n-BCA AVMs was 52% compared to 51% in Onyx AVMs. There were 2 periprocedural complications in the n-BCA cohort and none in the Onyx cohort.Conclusions: In this small retrospective series, Onyx and n-BCA achieved similar occlusion results, although n-BCA required more sessions and pedicles embolized to do so.

최신임상강좌 : 산후출혈의 치료를 위한 동맥색전술의 실패와 관련된 인자의 분석

소경아 ( Kyeong A So ),오윤경 ( Yoon Kyung Oh ),황효순 ( Hyo Soon Hwang ),홍혜리 ( Hye Ri Hong ),조금준 ( Geum Joon Cho ),오민정 ( Min Jeong Oh ),허준용 ( Jun Yong Hur ) 대한산부인과학회 2010 Obstetrics & Gynecology Science Vol.53 No.9

목적: 산후출혈로 동맥색전술을 시행한 환자들을 분석하여 동맥색전술의 실패의 원인과 관련된 인자들에 대하여 알아보고자 하였다. 연구 방법: 2004년부터 2008년까지 고려대학교 의료원에서 산후출혈로 동맥색전술을 시행한 60명의 환자의 진료 기록과 동맥 조영술 결과를 후향적으로 분석하여 성공군과 실패군을 비교하였다. 결과: 동맥색전술의 전체 성공률은 88.3% (53/60명)였고 실패한 경우는 11.7% (7/60명)였다. 색전술의 실패는 비정상태반인 경우 통계적으로 유의하게 높았으며 (P=0.034), 특히 태반 유착이 동반된 전치태반의 경우에서 더욱 그러하였다 (P=0.009). 각 대상군의 나이, 분만력, 분만 방법, 출혈시기, 전원 여부, 시술 전 수술 여부, 시술 시 활력징후, 시술 전 혈색소 수치, 분만 후 색전술까지 시간, 중환자실 치료 여부 등은 차이가 없었다. 결론: 산후출혈 환자에서 동맥색전술은 성공률이 높고 합병증이 적은 안전한 시술 방법이나 출혈의 원인이 비정상태반인 경우 동맥색전술이 실패할 가능성이 높다. Objective: To investigate what factors are associated with a failed arterial embolization for postpartum hemorrhage (PPH) and to attempt to estimate efficacy of arterial embolization. Methods: Between 2004 and 2008, 60 patients at Korea University Medical Cencter underwent arterial embolization to control obstetrical hemorrhage. In all cases, arterial embolization was performed because of intractable hemorrhage unresponsive to conservative management. Medical records and angiographic results were reviewed. Arterial embolization failure was defined as the requirement for subsequent surgical procedure to control PPH with the procedure, and its results. Results: Arterial embolization was attempted in 60 of deliveries. Failures occurred in 7 of 60 cases (11.7%) and in 4 of 7 cases (57.1%) of abnormal placentation (placenta previa totalis with or without placenta accrete or increta). Comparison of the failed and successful arterial embolization groups showed no differences in maternal characteristics, clinical status, and angiographic finding. Amount of total transfusion in failed arterial embolization group were larger than successful group although hemoglobin before embolization was not different. Conclusion: The only factor significantly associated with failed arterial embolization was an abnormal placentation. Arterial embolization is a safe and highly effective method to control PPH.

Helical coils augment embolization of the middle meningeal artery for treatment of chronic subdural hematoma: A technical note

Arvin R. Wali,Alexander Himstead,Javier Bravo,Michael G Brandel,Brian R. Hirshman,J. Scott Pannell,Andrew D. Nguyen,David R. Santiago-Dieppa 대한뇌혈관외과학회 2023 Journal of Cerebrovascular and Endovascular Neuros Vol.25 No.2

Embolization of the middle meningeal artery (MMA) is a safe and effective adjunct in the treatment of chronic subdural hematoma. While prior authors describe the use of coils to assist embolization by preventing reflux through eloquent collaterals, we de- scribe the use of coils to further open the MMA, allowing the administration of greater amounts of embolisate for a more robust embolization. The objective of this study was to demonstrate that helical coils can safely open the MMA following the administration of polyvinyl alcohol (PVA) particles. This allows for more embolisate to be administered into the MMA for more effective treatment. A retrospective review was conducted at our institution including intraoperative images and postoperative clinical and radiographic follow up. Failure rates using MMA embolization with PVA and helical coil augmentation were compared to failure rates in the literature of MMA embolization with PVA or ethylene vinyl-alcohol copolymer alone. A total of 8 cases were reviewed in which this technique was implemented. There were no immediate complications after treatment. All patients that underwent helical coil embolization following the administration of PVA had increased amount of embolisate delivered into the MMA. All patients at follow up had resolution of the subdural hematoma on outpatient imaging. Helical coil embolization allows for more embolisate administration into the MMA and provides a technical advantage for patients that fail traditional techniques of embolization. Case series are taking place to further test this hypothesis and identify the ideal patient population that may gain maximal yield from this novel technique.

난치성 후방 비출혈 환자에서 내시경하 접형구개동맥 소작술과 선택적 동맥 색전술의 비교 분석

정재환,김석현,문수진,홍성룡,노환중,조규섭 대한이비인후과학회 부산,울산,경남 지부회 2017 임상이비인후과 Vol.28 No.1

The purpose of this study was to compare treatment modality of ESPAL and arterial embolization in patients with intractable posterior epistaxis. Subjects and Methods:This study was a retrospective review of 16 patients with intractable posterior epistaxis. Twelve patients were treated with ESPAL and four patients with arterial embolization. Success rates, duration of procedure, hospital stay, hospital cost, postoperative complications were analyzed. Results:Rebleeding occurred in two patients treated with ESPAL. One patient was successfully controlled with reoperation. The other surgical failure was controlled with embolization due to SPA pseudoaneurysm. The success rate of ESPAL and embolization was 83.3% and 100%, respectively. Two of four patients received embolization had pseudoaneurysm in the descending palatine artery. The mean duration of procedure and hospital stay was 82.5 minutes and 8.1 days in ESPAL, but 96.7 minutes and 6.0 days in embolization, respectively. The mean total cost of ESPAL was 3,380,000 won, 4,090,000 won for embolization. There were no major complications in both groups. Conclusions:Both ESAPL and arterial embolization had similar high success rates in controlling intractable posterior epistaxis. However, arterial embolization may be a better initial option in patients suspected of pseudoaneurysm and in surgical failures.

뇌경막 동정맥루 환자에서 경정맥 색전술을 이용한 치료

이은주,윤웅,서정진,신상수,임효순,송상국,장남규,허숙희,강형근 대한영상의학회 2005 대한영상의학회지 Vol.53 No.4

목적: 뇌경막 동정맥루의 치료법으로서 경정맥 색전술의 유용성에 대해 알아보고자 한다. 대상과 방법: 2002년 10월부터 2004년 7월까지 혈관 조영술로 확진된 뇌경막 동정맥루 환자 8명에 대해 일차적인 치료법으로 경정맥 색전술을 시행하였다. 4명의 환자에서 경동맥 색전술을 함께 시행하였다. 남자가 5명, 여자가 3명이었으며, 연령분포는 45-78세였다(평균: 55.4세). 환자의 의무기록과 영상소견을 후향적으로 분석하였고, 임상적인 추적관찰기간은 5-24개월(평균: 16.5개월)이었다. 결과: 뇌경막 동정맥루의 위치는 6예가 횡정맥동-S자 정맥동에, 2예가 해면 정맥동에 발생하였다. Cognard 분류에 의한 I유형이 4예, IIa 유형이 2예, IIb 유형이 2예였다. 색전물질은 모든 환자에서 분리코일과 섬유부착 미세코일을 함께 사용하였다. 색전술 후 7예(88.9%)에서 혈관조영사진에서 동정맥루의 완전폐색을 보였고, 나머지 1예(11.1%)에서는 소량의 잔여 혈류가 관찰되어 부분치유로 판정하였다. 색전술 후 모든 환자에서 증상이 소실되거나, 호전되어 100%의 임상적인 성공율을 보였다. 시술과 관련된 합병증은 없었다. 1명에서 2개월 후 재발을 보여 이차적인 경정맥 색전술을 시행하였다. 그 외 7명은 추적기간동안 증상의 재발을 보이지 않았다. 결론: 뇌경막 동정맥루 환자의 치료법으로 경정맥 색전술은 효과적이고 안전한 치료법으로 생각된다. Purpose: To evaluate the efficacy of transvenous embolization in patients with dural arteriovenous fistula (DAVF). Materials and Methods: From October 2002 to July 2004, eight patients with angiographically confirmed DAVF underwent transvenous embolization of the affected dural sinuses. Concomitant transarterial embolization was performed in four patients. Patients included five men and three women aged 45-78 years (mean age, 55.4 years). The patient's medical records and angiographic features were retrospectively reviewed. Patients had follow-up periods ranging from 5 to 24 months (mean, 16.5 months). Results: The locations of DAVF were transverse - sigmoid sinus in six patients and cavernous sinus in two patients. According to Cognard's classification, four of the DAVFs were Type I, two were type IIa, and two were Type IIb. Embolic materials used for the transvenous embolization were platinum detachable coils and fibered microcoils. After the transvenous embolization, there was complete obliteration of the DAVF in seven patients and significant flow reduction in one patient. All cases were clinically successful. There were no transient or permanent complications as a result of the endovascular procedures in any of the patients. One patient who had symptom recurrence 2 months after the initial treatment was successfully treated with repeated transvenous embolization. The remaining seven patients had no symptom recurrence during the follow-up period. Conclusion: Transvenous embolization is an effective and safe method in the treatment of patients with DAVF.