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Transcatheter angiographic embolization for the control of massive pelvic hemorrhage due to gestational trophoblastic disease: a case series and review of the literature.

Pelvic hemorrhage, either uterine or vaginal, secondary to gestational trophoblastic disease (GTD) can be catastrophic and sometimes fatal. Surgical intervention, however, such as resection of vaginal lesions or internal artery ligation are invasive and not without untoward events. Angiographic embolization is emerging as a practical, safe, effective, and less invasive technique with excellent results. This case series describes four patients with internal or external hemorrhage due to GTD. Angiography and embolization was performed using the modified Seldinger technique with gelfoam particles. The advantages of this method include outpatient procedure, conscious sedation, and minimal discomfort to the patient with excellent results. We conclude that angiographic embolization should be the method of choice in such circumstances and should form part of the therapeutic armamentarium of every interventional radiologist.

Adult↗

PubMed1996

Preoperative portal vein embolization for extension of hepatectomy indications.

To render hepatectomy feasible in patients with an initially deficient volume of the future remnant liver (FRL), we redistributed portal blood flow rich in hepatotrophic substances toward the FRL. Redistribution was achieved with preoperative portal vein embolization (POPE) feeding the future resected liver. POPE was performed in 31 patients, under fluoroscopic guidance, via a percutaneous access. POPE was well tolerated and surgery was practicable in 24 patients without severe postoperative liver failure. Seven operations were cancelled, but only one due to insufficient hypertrophy of the FRL. FRL volume values were 90 to 560 mL (mean 260 mL) before POPE and 160-783 mL (mean 443 mL) after POPE, which represents a median increase of 79% +/- 50%. Hypertrophy of the FRL was 90% +/- 52% after 30 days with cyanoacrylate, 53% +/- 6% after 43 days with Gelfoam, and 44% +/- 30% after 35 days with coils. Slight shrinkage was obtained in the volume of the embolized liver, for which resection was planned. Overall survival was 2-62 months (mean 26 months), disease-free survival was 0-60 months (mean 19 months), and 7 patients are disease-free and alive 14 to 60 months (mean 43 months) after surgery. Although exclusively applicable in a limited subset of patients, POPE widens the possibilities of curative hepatectomies, because it induces sound hypertrophy of unembolized liver segments. Cyanoacrylate seems to ensure better and faster hypertrophy.

Adolescent↗

PubMed2002

Treatment of hepatocellular carcinoma with sub-selective transcatheter arterial oily chemoinfusion.

Transarterial therapy for primary liver cancer is gaining more acceptance. The technique of transarterial treatment of such cancers is, however, quite varied. To determine the value of our approach, we analyzed our experience with transarterial oily chemoinfusion (TOCI) of primary liver cancer over a 4.9-year period. Since 1997, over 300 such procedures have been performed at our institution. We report the results of the first 253 procedures, which were performed using a subsegmental technique with a mixture of doxorubicin, cisplatin, ethiodol, with selective Gelfoam embolization. Actuarial survival rates at 1, 2, and 3 years were calculated with Kaplan-Meier and multivariate analysis was performed by Cox regression. The median overall survival was 28.6 +/- 4.5 months following diagnosis. By univariate analysis, TNM clinical stage I or II, Karnofsky score above 80%, absence of extrahepatic disease, absence of vascular invasion, unifocal disease, pretreatment alpha-fetoprotein levels less than 500 ng/ml, hypervascularity of lesions, and lesion size less than 5 cm were all strong predictors of favorable patient survival at 1, 2, and 3 years (75%, 60%, and 50% respectively). Based on our experience, TOCI with selective embolization has similar survival benefit as the traditional chemoembolization but is associated with fewer complications.

Adult↗

PubMed1976

Current angiographic approach to diagnosis and therapy of acute gastrointestinal bleeding.

The author's current angiographic approach to the diagnosis and therapy of acute gastrointestinal (GI) bleeding is summarized and discussed. It is based on the authors' experience with diagnostic studies in more than 300 acute GI bleeders and the use of various angiotherapeutic techniques in 138 of them as well as the experience of others. A "moderately aggressive angiographic approach" is advocated for the diagnosis of acute GI bleeding in most patients with angiography used as needed after emergency endoscopy and preliminary medical therapy. Vasoconstrictive angiotherapy with selective intraarterial use of vasopressin is partially giving way to low dose, intravenous infusion of vasopressin and, where possible, to direct vascular occlusion. Selective transcatheter embolic occlusion of bleeding vessels is in indicated cases an accepted method for controlling arterial bleeding. Medical gelatin (Gelfoam) is the current authors' embolization material of choice. Selective variceal occlusion offers promising means for management of bleeding from gastroesophageal varices. Its possible combination with transcatheter intrahepatic portosystemic shunting might also provide non-surgical relief of portal hypertension.

Acute Disease↗

PubMed1978

Which embolic material is best suited for which embolization procedure?

Various embolization cases are described, and these require certain embolization materials. In our experience Gelfoam particles are very well suited for gastrointestinal tract lesions. Ivalon shavings gave excellent results in congenital arteriovenous malformations with permanent occlusions. Bristle brushes are a new device for larger artery occlusion. Stainless steel coils in combination with silk tufts proved thrombosis of large AV fistuals or of aneurysms particularly of the splenic artery.

Abdominal Injuries↗

PubMed2001

Basic fibroblast growth factor induced angiogenesis and prefabricated flap survival.

Prefabrication of a latissimus dorsi myocutaneous flap was performed in adult male Landrace pigs. Gelfoam sponges were used as a delivery system for basic fibroblast growth factor (bFGF) at the muscle-subcutaneous tissue interface. Skin survival and angiogenesis were augmented in the growth-factor-treated animals. These data support the use of basic fibroblast growth factor to enhance flap prefabrication.

Animals↗

PubMed2003

[Tympanoplasty with adipose tissue].

BACKGROUND: Among other materials it is also possible to use autologous fat tissue for closing tympanic membrane perforations. In this study we have evaluated 44 consecutive myringoplasties with adipose tissue performed between 1999 and 2001. MATERIAL AND METHOD: The indications were residual microperforations following tympanoplasty with temporalis fascia or tympanic membrane perforations due to trauma or chronic otitis media simplex. Myringoplasty with fat tissue was performed as an outpatient procedure and took about 15 minutes. The adipose tissue was harvested from the posterior side of the ear lobe in local anaesthesia. After refreshing the borders of the tympanic membrane perforation with a micro hook, the adipose tissue was positioned into the perforation by using a handheld or fixed ear speculum. The graft was covered with a silk strip soaked with Garamycine ointment. In bigger perforations a bed of gelfoam was put into the tympanic cavity in order to avoid adhesions between the graft and the promontorium. RESULTS: A permanent healing of the tympanic membrane was achieved in 40 (91 %) out of the 44 patients. In 21 patients hearing improved between 5 -10 dB. Surgical complications did not occur. CONCLUSIONS: Our results indicate that transcanal myringoplasty with adipose tissue is a simple and minimally invasive method for closing small to medium sized tympanic membrane perforations.

Adipose Tissue↗

PubMed1997

[Interventional treatment of hemobilia].

PURPOSE: Aim of the study was to assess the use of embolisation in cases of iatrogenic haemobilia. METHOD: In 18 patients with severe haemobilia after percutaneous biliary system drainage or stent implantation, an embolisation with minicoils (17 x) or gelfoam particles, was performed. To achieve a sufficient vascular obstruction, Histoacryl (4 x) or Ethibloc (1 x) were additionally used in five cases. A transarterial approach was used in 17 cases. In one patient, an approach through the biliary system was possible. RESULTS: In all cases, the bleeding source was identified (5 false aneurysms, three biliary leaks, 9 irregularities at the junction of the artery and drainage catheter, 1 multiple collaterals at the proximal end of the stent). In 17 out of 18 cases, haemorrhage ceased definitely. In one case of a patient with pancreas carcinoma and obstruction of the portal vein as well as a simultaneous high grade stenosis of the hepatic artery propria, it was only possible to embolise small collaterals to avoid liver necrosis. This resulted in an incomplete bleeding of control. An infected haematoma was the only complication. It was treated by drainage over 10 days. During an observation period ranging approximately 7.6 months, 10 of the patients died due to their basic illness. CONCLUSION: Embolisation is an effective procedure in the treatment of haemobilia, with a low complication rate.

Aged↗

PubMed1985

Primary management of postpartum vulvovaginal hematomas by angiographic embolization.

Three cases of large postpartum vulvovaginal hematomas are reported. After conservative measures including incision and drainage, ligation of bleeding sites, vaginal packing and replacement of volume and coagulation factors failed to control the bleeding in each, pelvic angiography was performed. Brisk arterial bleeding demonstrated on arteriography was controlled by Gelfoam embolization in all three cases. Intra- or postpartum hematologic evaluation revealed a previously undiagnosed coagulation disorder in each patient. The authors suggest that angiography be considered before hypogastric artery ligation whenever possible in patients with large postpartum hematomas and that all such patients be evaluated for coagulopathy.

Adult↗

PubMed1993

[The role of embolization treatment of acute hemorrhage].

137 arteries of 95 patients were treated by transcatheter embolization for massive haemorrhage using Ethibloc, Gelfoam, wire coils and Tissucol (Fibrinogen + Thrombin). The bleeding was secondary to trauma in 23 patients, to neoplasms in 16 patients and to vascular malformations or chronic inflammatory processes in 41 cases. 15 patients were treated for iatrogenic bleeding following surgery. Bleeding was referred to haemoptysis (n = 27), pelvic (n = 24), renal (n = 16) or gastrointestinal haemorrhage (n = 13) as well as several other diseases (n = 15). Most patients were poor surgical candidates. The overall bleeding control rate was 89.5% with a incidence of recurrent bleeding in 14 out of 95 patients (14.7%) treated by re-embolization or surgery. 6 patients died (6.3%) due to intractable haemorrhage, 4 patients (4.2%) died of complications related to embolization procedure (4 x bowel infarction!) and 33 patients (34.7%) died of procedure-unrelated causes such as myocardial infarction, trauma, malignancy or other underlying diseases. 58 patients (61.1%) are still alive (follow-up 16.2 +/- 4.8 months). Significant complications (5.3%) included bowel necrosis (4x) and ischaemia of the spinal cord with incomplete paralysis in one patient. One patient suffered thrombosis of the common iliac artery due to angiography. On the basis of our results, peripheral embolization using Ethibloc can be recommended as palliative treatment for devascularisation of bleeding tumours. Satisfactory results are obtained in haemoptysis, renal and pelvic haemorrhage, but gastrointestinal bleeding should not be occluded by means of Ethibloc because of its considerable risk of bowel infarction.

Acute Disease↗

PubMed1989

[Treatment of hemoptysis by embolization of the thoracic arteries with Ethibloc].

Between November 1983 and July 1988 28 patients with haemoptysis were treated by transcatheter embolisation. Clinical follow-up of 22 patients revealed that 5 patients rebled within 21 days after embolization. Haemoptysis ceased completely in the remaining 17 patients. However, 2 patients rebled after 4 and 12 months, respectively. We observed two transient spinal cord injuries, most likely related to spinal cord ischaemia. In the first patient an intercostal artery was embolised with Ethibloc, in the second patient with Gelfoam. In summary, we can say that due to the inherent risk of spinal cord injury, embolisation should be restricted to patients in whom other forms of treatment failed or proved impossible. Ethibloc may be alternatively used for embolisation.

Adult↗

PubMed1980

[Capillary embolization. Part I: occlusion of the entire arterial system of the rat kidney (author's transl)].

Effect of tumor embolization is limited by parasitary blood supply. The influence of those collaterals should be decreased by transporting the embolization medium into the capillaries and tumor sinusoids. Controlled and safe capillary embolization is developed from studies of obtainable radiodensity, viscosity, and occlusion mechanism of Gelfoam-powder, IBC, and Ethibloc. The efficiency of these substances is compared to simple arterial ligation in experimental series with 400 Wistar rats. It is shown that ligation is comparable to insufficient capillary transport of the medium leaving islands of microscopically intact parenchyma. Easy application and total necrosis is guaranteed only by Ethibloc. Success of embolization is strictly volume dependent. Preinjected glucose is mandatory for homogenous distribution and peripheral transport.

Animals↗

PubMed1981

[Capillary embolization. Part II. Occlusion of the entire arterial system of experimentally induced renal tumors ].

221 renal rat tumors (induced by Dimethylnitrosamine) are embolized by gelfoam powder, IBC/Lipiodol and Ethibloc/Glucose. The effect of those embolization media is compared to ligation and glucose perfusion. Recurrencies and rate of surviving tumor tissue are dependent on the stage of the neoplasm, sufficient capillary propagation of the medium, and exact volume-dependent embolization. It could be proven that large areas of renal rat tumors are equally supplied by the main artery and parasitary collaterals. Only homogeneous distribution and complete downstream propagation of the embolization medium from the main artery to the capillaries will achieve breakdown of this parasitary supply. Glucose governed Ethibloc embolization achieves in 80% of tumors with a 6 fold renal volume and in 50% of larger tumors complete necrosis. It has the lowest complication rate of all tested materials.

Animals↗

PubMed1995

A comparison of lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma.

BACKGROUND: Chemoembolization with lipiodol (iodized oil) is widely used to treat patients with unresectable hepatocellular carcinoma. Severe side effects have been reported, and improved survival has not been clearly demonstrated. METHODS: Patients with unresectable hepatocellular carcinoma who did not have severe liver disease and who met additional entry criteria were randomly assigned to receive either lipiodol chemoembolization (70 mg of cisplatin, 10 ml of lipiodol, and gelatin-sponge [Gelfoam] particles delivered through the hepatic artery) or conservative management involving treatment of complications and pain. Courses of treatment were to be given every two months for a maximum of four courses. The main end point was survival. RESULTS: The study was stopped in December, 1992, after a sequential analysis showed the lack of the expected benefit from chemoembolization. As of October 1, 1994, 39 of the 50 patients assigned to chemoembolization and 40 of the 46 patients assigned to conservative management had died. Twenty-six patients assigned to chemoembolization received all four courses of treatment. There was no significant difference in survival between the two groups, although there was a trend favoring the chemoembolization group (estimated relative risk of death in the control group, 1.4; 95 percent confidence interval, 0.9 to 2.2; P = 0.13). The comparison of survival between the two groups was not substantially changed by adjustments for differences in base-line and prognostic characteristics (adjusted relative risk, 1.3; 95 percent confidence interval, 0.8 to 2.1; P = 0.31). At one year, the estimated survival rates were 62 percent in the chemoembolization group (95 percent confidence interval, 48.6 to 75.4 percent) and 43.5 percent in the conservative-management group (95 percent confidence interval, 29.2 to 57.8 percent). In the chemoembolization group, tumor growth, as assessed by tumor size and serum alpha-fetoprotein concentration, was reduced and the incidence of portal obstruction was lower than in the conservative-management group. Liver failure occurred after 47 courses of treatment in 30 patients assigned to chemoembolization. CONCLUSIONS: In a group of patients with unresectable hepatocellular carcinoma but without severe liver disease, lipiodol chemoembolization reduced tumor growth, often caused acute liver failure, and did not significantly improve survival.

Adult↗

PubMed2002

Improved heart function with myogenesis and angiogenesis after autologous porcine bone marrow stromal cell transplantation.

OBJECTIVE: The study evaluated the utility of transplanting bone marrow stromal cells in a porcine myocardial infarction model. METHODS: A myocardial infarction was created by occluding the distal left anterior descending artery in pigs with coils and Gelfoam sponge. Sternal bone marrow was aspirated, and stromal cells were cultured and induced to differentiate to a myogenic phenotype with 5-azacytidine. Four weeks after coronary artery occlusion, sestamibi technetium single-photon emission computed tomographic scans were performed, and then either a graft of 100 x 10(6) bone marrow stromal cells (n = 5, 30% labeled with bromodeoxyuridine) or culture medium (n = 6) was injected into the infarct region. Four weeks later the tomographic scans were repeated and cardiac function was assessed with pressure and volume measurements. Morphologic and histologic characteristics of the heart were also studied. RESULTS: Histologic examination found bromodeoxyuridine-labeled cells within the infarct region in islands that had sarcomeres and Z-bands and stained positively for cardiac specific troponin I. The bone marrow stromal cell transplant sites had a greater (P <.05) capillary density than did the control sites. The tomographic scans showed that the hearts with the cell transplants had increases in stroke volume, regional perfusion, and wall motion (P <.05 for all groups) relative to the control hearts. The pressure-volume analysis showed improvement (P <.05) in end-systolic elastance and preload recruitable stroke work in the transplantation group relative to the control group. The left ventricular chamber size was smaller (P <.05) and the scar thickness was greater (P <.05) in the hearts with transplanted cells than in the control hearts (P =.06). CONCLUSION: 5-Azacytidine-treated bone marrow stromal cells transplanted into the myocardial infarct region formed islands of cardiac-like tissue, induced angiogenesis, prevented thinning and dilatation of the infarct region, and improved regional and global contractile function.

Animals↗

PubMed2001

Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: a complication in the management of a type II endoleak.

The optimal management of endoleaks after endovascular repair of abdominal aortic aneurysms remains to be established. In this report, we describe a persistent side-branch, or type II, endoleak 1 year after endograft implantation treated with catheter-directed embolization of the aneurysm sac and the inferior mesenteric artery via the superior mesenteric artery, with embolization agents including thrombin, lipiodol, and gelfoam powder. Shortly after the embolization procedure, colonic necrosis developed in the patient, manifested by peritonitis, which necessitated a partial colectomy. This case underscores the devastating complication of colonic ischemia as a result of catheter-directed embolization of the inferior mesenteric artery in the management of an endoleak.

Aged↗

PubMed1995

A 13-Mer peptide of a brain injury-derived protein supports neuronal survival and rescues neurons from injury caused by glutamate.

Neuronal survival is mediated by several kinds of proteins. Among these, neurotrophic factors play important roles in the nervous system by supporting neuronal activity and survival. It has been suggested recently that certain factors promote neuronal survival in the case of brain injury. To examine this possibility, we purified a novel neurotrophic factor from Gelfoam that was implanted at the site of injury caused in neonatal rats. During amino acid sequence analysis, we found that a fragmental peptide of this neurotrophic protein consisting of 13 amino acids showed neurotrophic activity. This 13-mer peptide promoted survival of septal cholinergic and mesencephalic dopaminergic neurons in culture and rescued hippocampal neurons from injury caused by glutamate in culture. This peptide rescued neurons from cell death caused by glutamate, even when added 4.5 h after glutamate exposure.

Amino Acid Sequence↗

PubMed2002

Neuroprotective effect of nipradilol on axotomized rat retinal ganglion cells.

PURPOSE: To determine whether nipradilol, a new anti-glaucoma drug, can protect retinal ganglion cells (RGCs) from secondary cell death caused by transection of the optic nerve (ON). METHODS: The ON was transected 0.7 mm from its exit from the eye in Sprague Dawley rats. Nipradilol (1 x 10(-8) - 10(-3) M), timolol, prazosin, or sodium nitroprusside (SNP) (1 x 10(-6) - 10(-4) M) was injected intravitreally fifteen-minutes before the ON transection. Control eyes received the same amount of phosphate buffered (PB). The RGCs were labeled retrogradely by placing gelfoam soaked in fluoro-gold (FG) on the stump of ON. RGCs density was determined by counting the FG-labeled RGCs in flat-mounted retinas 3 to 14 days post-transection. To determine whether the neuroprotective action of nipradilol was due to its NO-donor property, carboxy-PTIO, a NO-scavenger, or KT5832, a protein kinase G inhibitor, was injected with the nipradilol. RESULTS: After ON transection, the number of surviving RGCs after intravitreal injection of 1 x 10(-4) M nipradilol was significantly higher than that following PB injection. This protective activity was dose-dependent. Neither timolol nor prazosin had a neuroprotective effect but SNP protected RGCs in a dose-dependent manner. Carboxy-PTIO and KT5832 decreased the neuroprotective effect of nipradilol. CONCLUSIONS: These results indicate that nipradilol has a possibility of neuroprotective effect on axotomized RGCs, and the effect depended mainly on its NO-donor property.

Adrenergic Antagonists↗