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We describe an application of simple scintigraphic localization of therapeutic gelatin emboli during and after transcatheter arterial embolization using gelatin particles labeled with technetium 99m. This scintigraphy required an additional 15-30 minutes and can be useful for prevention of serious complications and for early detection of adverse embolisms.
Over the past 7 years, eight patients with splanchnic artery aneurysms and pseudoaneurysms were studied and treated. Transcatheter embolization resulted in occlusion of the lesions in all eight patients. Potentially risky and difficult surgery was avoided completely in four patients. Three patients had elective surgery at a later date when their condition was more stable. The remaining patient had definitive surgery after embolization. Transcatheter embolization should be the initial treatment of choice in splanchnic artery aneurysms and pseudoaneurysms.
Thirty-one patients with hepatocellular carcinoma (HCC) were given either an intraarterial injection of iodized poppyseed oil (Lipiodol) alone (group A, n = 6), an emulsion of iodized oil and doxorubicin hydrochloride (Adriamycin) (group B, n = 15), or chemoembolization with the same emulsion followed by gelatin sponge (Gelfoam) particles (group C, n = 10). Hepatic resection was subsequently performed. The frequencies of complete necrosis of tumor in the main lesion, daughter tumors, tumor thrombus, and foci of intracapsular invasion were evaluated in the cut surface of the resected specimen. Group C demonstrated the best therapeutic effects, showing complete necrosis of the main lesion in 83% (P less than .01), daughter tumors in 53% (P less than .01), tumor thrombus in 17%, and foci of intracapsular invasion in 67%. These results are superior to those reported previously for chemoembolization without iodized oil. Group B showed better results than group A, but the difference was not significant. Iodized oil alone (group A) had practically no therapeutic effect but was helpful in differentiating small HCC from regenerative nodules.
Injury of the lumbar arteries is a cause of potentially life-threatening retroperitoneal hemorrhage. Twelve patients who sustained massive hemorrhage of the lumbar arteries associated with lumbar spinal fractures and/or pelvic fractures are described. Computed tomography (CT) was helpful by revealing a distinct separation of the lumbar hemorrhage from the hematomas associated with pelvic fracture. On arteriograms, stasis within lumbar extravasation was manifested as globular or streaky accumulations of contrast medium, pseudoaneurysms or diffuse "staining," or opacification of a fracture site. Multiple lumbar bleeding sites were seen frequently. Embolization with pledgets of absorbable gelatin sterile sponge controlled bleeding in ten patients. Abdominal aortography should be an essential part of the arteriographic evaluation of retroperitoneal hematomas associated with pelvic fractures, especially when there are lumbar fractures. Selective lumbar arteriography should be performed for confirmation when there is suspicion of lumbar artery injury on the basis of aortographic findings. Embolization with pledgets of surgical gelatin is effective in controlling hemorrhage from these injuries.
Congenital arteriovenous malformations (AVMs) involving the pelvis or an extremity were occluded in 16 symptomatic patients, who subsequently underwent tailored embolotherapy. An additional 11 patients did not undergo embolization due to unfavorable vascular anatomy or lack of significant symptoms. Permanent occlusive agents including isobutyl cyanoacrylate, particles of polyvinyl alcohol foam, and coils were used to embolize the multiple feeding vessels and, when possible, the nidus of the AVM. All patients experienced dramatic reduction in pain and resolution of ulceration and bleeding, with a mean follow-up period of 41 months. Symptoms recurred in four patients but again resolved with repeat embolization. The authors conclude that selective and repetitive embolization is highly effective in palliation of symptomatic congenital AVMs.
Since 1983, transcatheter oily chemoembolization (TOCE) with doxorubicin hydrochloride, iodized oil, and gelatin sponge was used in 100 patients with hepatocellular carcinoma. Doxorubicin, 40-100 mg (mean, 61.3 mg), was mixed with 5-20 mL (mean, 9.6 mL) of an iodized oil to prepare a water-in-oil emulsion that was then infused into the hepatic artery. Both progressive changes in blood concentrations of doxorubicin and its tissue concentrations in patients who underwent hepatectomy demonstrated that the drug was released slowly from the emulsion. The cumulative survival rate was 82.0% for 6 months, 53.8% for 1 year, 33.3% for 2 years, and 17.6% for 3 years. These survival rates were better than those of 104 patients who underwent embolization with gelatin sponge, then received an anticancer drug (67.4% for 6 months, 45.2% for 1 year, 16.3% for 2 years, and 3.8% for 3 years).
Renal platinum distributions were determined in rabbits after administration of 0.4 mL of 1 mg/mL cisplatin by intravenous infusion, by injections into the left renal artery with aqueous contrast material and with lipid contrast material (Ethiodol), and by chemoembolization of the left renal artery with concurrent administration of various concentrations of two collagen carriers, Angiostat collagen for embolization and Gelfoam gelatin. Renal platinum concentration was measured in tissue homogenates at 2 1/2 hours with atomic absorption spectrometry. Target-kidney platinum levels were 5.4 and 6.9 times the contralateral-kidney levels after intraarterial infusion of aqueous and lipid contrast media, respectively. With Angiostat and Gelfoam chemoembolization, renal platinum retention and collagen concentration were linearly related (r = .87 and .81, P less than .001). Target-kidney-contralateral-kidney platinum ratios were 57:1 for 30 mg/mL Gelfoam and 220:1 for 10 mg/mL Angiostat. The difference in regional drug retention for Angiostat versus Gelfoam reflects the stable fiber integrity of Angiostat.
The authors report an initially successful left gastric artery embolization performed because of massive upper gastrointestinal bleeding; the procedure was complicated by focal gastric and hepatic infarctions. These complications occurred in the absence of underlying factors known to predispose to ischemia. Low-grade gastric bleeding persisting after seemingly successful embolization of the left gastric artery may indicate ischemic gastritis and is an indication for endoscopy. In addition, the presence of a left hepatic artery completely replaced to the left gastric artery should alert one to the potential for hepatic necrosis.
Subselective embolization was performed in 15 patients with the use of gelatin sponge injected through a 0.038-inch open-ended guide wire. Eight patients were being treated for acute bleeding, and seven underwent elective embolization of tumors (hepatic, pelvic, spinal) or arteriovenous malformations. The procedure was successful in all 15 patients, and there were no major complications. The open-ended guide wire can be used safely and effectively in selective embolization with gelatin sponge. It is more flexible than the 3-F Teflon catheters and less expensive than the 2.2-F tapered catheters now being used for this purpose.
Preoperative embolization of vascular metastatic tumors of the spine, particularly carcinomas of renal and thyroid origin, is an adjuvant technique that significantly decreases the intraoperative blood loss and resultant surgical morbidity. Surgical decompression was achieved in 24 spinal vascular metastatic lesions, 20 of which were treated with preoperative embolization and four of which were not. The embolic materials used were gelatin sponge, polyvinyl alcohol foams, and metallic coils. In patients who underwent adequate embolization, an average of 1,850 mL of estimated blood loss was reported; in those who underwent inadequate or no embolization, greater than 3,500 mL of estimated blood loss occurred. When gelatin sponge is used, surgery should be performed within 24 hours to prevent preoperative recanalization.
Thirty patients with intractable idiopathic epistaxis were treated with endovascular therapy. Embolization of the internal maxillary artery controlled the epistaxis in 87% of the patients, and the success rate was increased to 97% after supplemental embolization of the facial artery. The only complication observed was transient postembolization hemiparesis, which occurred in one of the 30 patients. Intractable idiopathic epistaxis is defined as epistaxis of unknown cause that is refractory to nasal packing. Such epistaxis is commonly treated with surgical intervention, including ligation of the terminal segments of the internal maxillary artery and the ethmoid arteries. An alternative approach is performance of endovascular therapy. In our opinion, embolization is a safe and effective procedure when it is carried out by appropriately trained personnel. In most patients, its performance requires use of only neuroleptanalgesia; surgery can be avoided, and the duration of hospitalization is significantly shortened. We recommend that embolization be adopted as the primary modality for the treatment of idiopathic intractable epistaxis.
The effectiveness of pleural sealing with a compressed collagen foam plug in preventing the development of pneumothorax was evaluated in a prospective, comparative study of 50 patients undergoing transthoracic needle biopsies. The 4-cm-long plug was deposited through the thin-walled guidance needle at the end of the procedure in a position where it would cross both the visceral and the parietal pleura. The prevalence of postbiopsy pneumothorax was 28% (seven of 25 patients) in the control group and 8% (two of 25 patients) in the plug group. In each study group, two patients with pneumothoraces required chest tubes. Although further experience is necessary, the authors conclude that transpleural collagen foam plug placement may be an effective supplement for transthoracic needle biopsies.
The therapeutic effectiveness of a new combination therapy--pretreatment with transcatheter arterial embolization (TAE) and subsequent percutaneous ethanol injection (PEI)--for solitary large (> 3.0 cm in diameter) primary hepatocellular carcinoma lesions was compared with that of TAE alone. With TAE alone, a partial response of the tumor was seen in only 10% of the patients, and the 1-, 2-, and 3-year survival rates were calculated to be 68%, 37%, and 0%, respectively. Histologic examination of specimens obtained at hepatectomy showed that TAE alone caused complete necrosis in only 20% of the tumors. In contrast, PEI combined with TAE significantly (P < .05) increased the partial response rate (45%) and significantly (P < .01) prolonged the 1-, 2-, and 3-year survival rates (100%, 85%, and 85%, respectively). Combination therapy caused complete histologic necrosis in 83% of the tumors. It also was significantly (P < .05) better than TAE alone in terms of rate of primary tumor recurrence during follow-up.
Preoperative and postoperative magnetic resonance (MR) images obtained in 25 patients with pituitary macroadenomas (1.1-5.2 cm in diameter) were evaluated to determine normal (physiologic) and abnormal findings after transsphenoidal or subfrontal surgery. With a 1.5-T unit, T1-weighted sagittal and coronal images were obtained before and after administration of gadopentetate dimeglumine. The physiologic changes after surgery included resorption of packing material and sphenoid sinus opacifications, reexpansion of the pituitary gland, and lowering of the optic chiasm. Implanted gelatin foam appeared as an endosellar, circularly enhancing mass that was seen on follow-up studies to have decreased in size. Muscle-and-fat implants appeared as areas of high signal intensity. In 14 patients, residual tumors were found in the suprasellar (n = 4), retrosellar (n = 3), parasellar (n = 8), and/or endosellar (n = 3) space. Residual tumors were differentiated from implant materials by means of location, characteristic signal intensity, and enhancing pattern, which were identical to those of the corresponding preoperative adenoma in 13 cases (93%). Preoperative studies and clinical information are helpful in the evaluation of postoperative MR imaging examinations.
To define the intrahepatic distribution of iodized poppyseed oil and its effect on the liver, hepatic artery embolization (HAE) was performed in five mice, 12 rats, four rabbits, and 21 pigs with the iodized oil alone or in combination with gelatin sponge powder (GSPow) in three rats or gelatin sponge particles (GSPs) in nine pigs. All mice, rats, and rabbits underwent radiography of the upper abdomen and in vivo microscopy of the hepatic periphery during and immediately after injection and 1, 4, and 24 hours later. All pigs underwent angiography before and after HAE as well as measurement of portal venous pressure before HAE and 15, 30, 45, and 60 minutes and 4 weeks after HAE. Follow-up radiographs were obtained in 18 pigs. HAE performed with the iodized oil only was well tolerated by the liver, even when high doses were used, likely because of continuous flushing of the sinusoids by high blood flow from peripheral arterioles. When HAE was performed with the iodized oil and GSPow, this blood flow ceased and necrosis developed. The degree of necrosis after HAE with the iodized oil in combination with GSPs was directly associated with the dose of iodized oil. HAE performed with GSPs only did not cause damage.
PURPOSE: The authors report their experience treating progressive liver metastases from carcinoid tumor with doxorubicin, iodized oil, and gelatin sponge embolization. MATERIALS AND METHODS: Of 23 patients, 18 had carcinoid syndrome and 19 had elevated urinary 5-hydroxyindoleacetic acid (5-HIAA) levels. Relief of symptoms, changes in 5-HIAA levels, and changes in tumor size could be evaluated in 10, 11, and 17 patients, respectively. RESULTS: Symptomatic response was complete (average duration, 29 months) in 70% and partial in 30% of evaluated patients. Biologic response was complete (average duration, 21 months) in 73%, partial in 18%, and minor in 9% of evaluated patients. Morphologic response was complete in 11%, partial in 24%, and minor in 24% of evaluated patients. Survival after diagnosis of primary tumor, diagnosis of hepatic metastases, and first chemoembolization was 81, 47, and 24 months, respectively. Eight patients were alive at the end of the study. No mortality was related to chemoembolization. CONCLUSION: Chemoembolization is safe and effective for palliation of carcinoid liver metastases.
PURPOSE: To discuss the mechanism of multiple intrahepatic aneurysm formation after transcatheter arterial embolization (TAE) performed in five patients with hepatocellular carcinoma. MATERIALS AND METHODS: TAE was performed with gelatin sponge particles and iodized oil as embolic materials. Mitomycin C was also used in four cases. RESULTS: Three to 14 aneurysms 1-6 mm in diameter were found in third-to sixth-order branches of the hepatic arteries at repeat angiography performed 25-45 days after TAE. Follow-up angiograms in three cases revealed that most aneurysms were no longer apparent except in one patient in whom two aneurysms remained and were larger than before. In none of the five cases were any signs of aneurysm rupture noted. CONCLUSION: Radiologists should be aware of this complication of TAE. It is speculated that the main cause of aneurysm formation in these patients was the embolic agents used.
PURPOSE: To evaluate the effect of transcatheter management of hepatocellular carcinoma (HCC) on survival. MATERIALS AND METHODS: A prospective trial of transcatheter arterial embolization (TAE) was performed in patients with unresectable HCC. Three hundred twenty-two patients (265 men, 57 women; age range, 30-83 years) underwent TAE alone: 60 patients underwent TAE with gelatin sponge (GS) that contained anticancer agents (protocol 1); 78, TAE with GS and iodized oil mixed with anticancer agents (protocol 2); and 159, TAE with iodized oil with anticancer agents (protocol 3). A Cox proportional hazard model was used to analyze prognostic factors. RESULTS: In the randomized group (n = 272), survival rates for protocols 1, 2, and 3 were 80.4%, 86.3%, and 65.9%, respectively, at 1 year. Findings of analysis of prognostic factors showed that extrahepatic metastases, ascites, tumor extension, and icterus were the important factors. CONCLUSION: TAE with GS was superior to TAE without GS. Patient characteristics were important factors for survival.