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Control of Inferior Epigastric Arterial Bleeding with Percutaneous Suture and Thrombin Injection after Coil Embolization Failure
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Special Letters Section
a Celect filter penetrating into the L4 vertebra and causing iliopsoas abscess (3). The fractured strut and filter described in that report were removed surgically. The mainstay of treatment of iliopsoas abscess and spondylodiscitis is antibiotic therapy with percutaneous drainage of the abscess (4). In the patient described here, the iliopsoas abscess and spondylodiscitis were completely resolved with this treatment, with no need for open surgical intervention. Surgical drainage is usually reserved for patients with gas-forming iliopsoas abscess and acute neurologic compression. In conclusion, we report a case of penetration of IVC filter into the lumbar disc space causing spondylodiscitis and iliopsoas abscess that was treated with percutaneous drainage and antibiotic therapy.
REFERENCES 1. Zhou D, Moon E, Bullen J, Sands M, Levitin A, Wang W. Penetration of celect inferior vena cava filters: retrospective review of CT scans in 265 patients. AJR Am J Roentgenol 2014; 202:643–647. 2. Dinglasan LA, Trerotola SO, Shlansky-Goldberg RD, Mondschein J, Stavropoulos SW. Removal of fractured inferior vena cava filters: feasibility and outcomes. J Vasc Interv Radiol 2012; 23:181–187. 3. Rana MA, Gloviczki P, Kalra M, Bjarnason H, Huang Y, Fleming MD. Open surgical removal of retained and dislodged inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2015; 3:201–206. 4. Hsieh MS, Huang SC, Loh el-W, et al. Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study. BMC Infect Dis 2013; 13:578.
Control of Inferior Epigastric Arterial Bleeding with Percutaneous Suture and Thrombin Injection after Coil Embolization Failure
Gnerre et al
’
JVIR
thrombin injection and full-thickness abdominal wall suturing. This case report did not require review and approval by our institutional review board. A 61-year-old woman with a history of alcoholic liver cirrhosis (Model for End-stage Liver Disease score of 31) was admitted from the emergency department for decompensated cirrhosis with hepatic encephalopathy and acute kidney injury. Anemia developed in the patient during the course of her hospitalization. Despite multiple blood transfusions, her hemoglobin level decreased from 11.6 g/dL at admission to a nadir of 5.1 mg/dL on hospital day 20. She was transferred to the medical intensive care unit for close monitoring. In the medical intensive care unit, her condition became hemodynamically unstable, with a hemoglobin level of 4.7 mg/dL, heart rate of 143 beats per minute, and blood pressure of 86/43 mm Hg. Vasopressor support and large-volume transfusion of blood products were initiated. On hospital day 21, a computed tomographic (CT) angiogram of the abdomen and pelvis demonstrated active hemorrhage from the right IEA (Fig 1). She was taken emergently to the interventional suite, and, under general anesthesia, a right external iliac arteriogram demonstrated an actively bleeding right IEA branch (Fig 2a). The skin overlying the bleeding site was marked and determined to be the site of daily subcutaneous enoxaparin injections; given the thin body wall, this was likely the inciting event. The right IEA was selected. Glue embolization was considered; however, the procedure was performed emergently after hours by a single operator. The bleeding site was embolized above and below the site of bleeding with 3-mm and 5-mm pushable feathered microcoils (Cook, Bloomington, Indiana; Fig 2b).
From: Jeffrey Gnerre, MD Marc Michael D. Lim, MD Shekher Maddineni, MD Department of Radiology Westchester Medical Center 100 Woods Rd. Valhalla, NY 10595
Editor: Inferior epigastric artery (IEA) injury is a complication of abdominal wall surgery, trauma, or interventional procedures (1–3). Patients with end-stage liver disease who present with hemorrhagic ascites as a result of IEA injury frequently have a superimposed coagulopathy (2). We describe a patient with end-stage liver disease and coagulopathy with life-threatening bleeding of the right IEA that was refractory to coil embolization and successfully treated with a combination of percutaneous None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.05.013
Figure 1. Axial arterial-phase CT image of the midabdomen demonstrates hemoperitoneum with active extravasation originating from a branch of the right IEA (circle).
Volume 27
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Number 11
’
November
’
2016
1733
Figure 2. (a) Selective catheter-based arteriogram of the right external iliac artery before embolization demonstrates active extravasation (arrow) originating from a branch of the right IEA. The right IEA was selected and embolized above and below the site of bleeding with 3-mm and 5-mm coils. (b) Early arterial-phase image obtained immediately after coil embolization demonstrates residual flow within the right IEA (blue arrow) extending to the site of bleeding (yellow arrow). Additional coil embolization of the right IEA to its origin was performed, and a subsequent subtraction angiogram (c) does not demonstrate continued active extravasation of contrast medium.
Figure 3. Axial image from a CT angiogram of the abdomen and pelvis demonstrates metallic coils (red arrow) in the right IEA with adjacent active extravasation from a lateral branch (white arrow). There is a subjacent hematoma, as well as largevolume ascites, which displace bowel (asterisks) away from the bleeding vessel.
A subsequent arteriogram demonstrated persistent bleeding from the embolized IEA branch (Fig 2b). Coil embolization of the right IEA was continued to its origin to ensure that all potentially feeding branch vessels were embolized. A postembolization angiogram demonstrated
no evidence of continued active extravasation of contrast medium (Fig 2c). Immediately following the procedure, the patient’s blood pressure (112–131/48–75 mm Hg) and heart rate (69–88 beats per minute) stabilized. However, after 24 hours, her condition again became hemodynamically unstable, with a hemoglobin decrease to 6.8 mg/ dL, requiring blood product transfusion. A repeat CT angiogram obtained 48 hours after the initial embolization demonstrated continued bleeding from the same right IEA branch (Fig 3). She was returned to the interventional suite, and, under CT fluoroscopy, a 22-gauge spinal needle was inserted into the area of the bleeding, localized by using coils as a landmark. A total of 400 U of thrombin (1,000 U/mL; King Pharmaceutical; Bristol, Tennessee) was injected. Three percutaneous size 0 nylon sutures (Ethicon, Somerville, New Jersey) were then placed through the skin, rectus musculature, and fascia of the abdominal wall above and below the site of the bleeding. During the next 24 hours, the patient’s hemoglobin level stabilized to her usual baseline level of approximately 10.5 mg/dL without the need for continued transfusion, and vasopressor support was discontinued. Eight days after the second embolization, her condition stabilized sufficiently for transfer from the medical intensive care unit to the general floor. The patient died 16 days after the second intervention after developing acute respiratory decompensation with refractory shock secondary to liver failure. Spitzer et al (4) described five patients with IEA injury who were successfully treated with percutaneous
1734
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Special Letters Section
transabdominal sutures. However, these were placed under laparoscopic guidance. The combination of percutaneous thrombin injection with full-thickness abdominal wall sutures has not been previously described to our knowledge. In the present case, it is difficult to determine with certainty whether occlusion was ultimately achieved as a result of the thrombin, sutures, or the combination thereof. Additionally, initial occlusion of the IEA and branching vessels may have been unsuccessful, necessitating further intervention. The most concerning potential complication of our proposed treatment is bowel injury from closed placement of abdominal wall sutures. In the present case, the large-volume ascites displaced bowel posteriorly. Additionally, cutaneous necrosis is a consideration in placement of transabdominal sutures (4). However, with superficial vessels like the IEA, collateral vasculature to the skin and muscle minimizes this risk. In conclusion, percutaneous thrombin injection in combination with full-thickness abdominal wall suturing provides a novel and minimally invasive treatment for IEA injury. With appropriate planning, this may be an additional line of treatment in patients with coagulopathy or whose condition is refractory to coil embolization.
REFERENCES 1. Georgiadis GS, Souftas VD, Papas TT, Lazarides MK, Prassopoulos P. Inferior epigastric artery false aneurysms: review of the literature and case report. Eur J Vasc Endovasc Surg 2007; 33:182–186. 2. Sobkin PR, Bloom AI, Wilson MW, et al. Massive abdominal wall hemorrhage from injury to the inferior epigastric artery: a retrospective review. J Vasc Interv Radiol 2008; 19:327–332. 3. Yalamanchili S, Harvey S, Friedman A, Shams J, Silberzweig J. Transarterial embolization for inferior epigastric artery injury. Vasc Endovasc Surg 2008; 42:489–493. 4. Spitzer M, Golden P, Rehwaldt L, Benjamin F. Repair of laparoscopic injury to abdominal wall arteries complicated by cutaneous necrosis. J Am Assoc Gynecol Laparosc 1996; 3:449–452.
Staged Particle and Ethanol Embolotherapy of a Symptomatic Pancreatic Arteriovenous Malformation
Frenk et al
’
JVIR
Care, Department of Surgery (T.E.C., P.J.F.) and Division of Nephrology, Department of Medicine (J.C.) Massachusetts General Hospital Harvard Medical School, 55 Fruit St. Boston, MA 02119
Editor: Pancreatic arteriovenous malformations (AVMs) are rare. Although sometimes asymptomatic, many present with abdominal pain, gastrointestinal bleeding, or pancreatitis (1). This letter describes a pancreatic AVM treated with staged embolization with particles and absolute ethanol. This case report was exempted from institutional review board approval. A 54-year-old man presented with necrotizing pancreatitis. Computed tomography (CT) demonstrated an AVM in the pancreatic head and body (Fig 1). The patient underwent transgastric endoscopic pancreatic necrosectomy via an Axios stent (Xlumena, Mountain View, California) and was discharged home. One week later, he was readmitted with hemorrhagic shock from hematemesis and hematochezia. An angiogram obtained under general anesthesia identified branches from the transverse pancreatic, left gastric, splenic, and replaced right hepatic arteries supplying the AVM (Fig 2). Given the patient’s hemodynamic instability and the complexity of the AVM, the dominant supplying artery was targeted for particle embolization to stabilize the patient’s condition emergently. One branch arising from the transverse pancreatic artery was catheterized with a Renegade HIFLO microcatheter (Boston Scientific, Marlborough, Massachusetts), and embolization was performed with 500–700-μm and 700–900-μm tris-acryl gelatin microspheres (BioSphere, Roissy, France) and Gelfoam (Pharmacia and Upjohn, Kalamazoo, Michigan). The patient’s condition stabilized. After discussion in a multidisciplinary meeting, the decision was made to embolize the other supplying arteries with absolute ethanol in a staged approach. In a second procedure under general anesthesia, after assessing the flow pattern and estimating the required volume with test hand-injections, a branch from the left
From: Nathan E. Frenk, MD Tiffany E. Chao, MD, MPH Jie Cui, MD Peter J. Fagenholz, MD Zubin Irani, MD Division of Interventional Radiology, Department of Radiology (N.E.F., Z.I.) Division of Trauma, Emergency Surgery and Surgical Critical
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.06.015
Figure 1. Axial contrast-enhanced CT shows the conglomerate of abnormal vessels in the pancreatic body (dashed outline). Surrounding inflammatory changes from pancreatitis (arrows) are also seen.
’
Special Letters Section
a Celect filter penetrating into the L4 vertebra and causing iliopsoas abscess (3). The fractured strut and filter described in that report were removed surgically. The mainstay of treatment of iliopsoas abscess and spondylodiscitis is antibiotic therapy with percutaneous drainage of the abscess (4). In the patient described here, the iliopsoas abscess and spondylodiscitis were completely resolved with this treatment, with no need for open surgical intervention. Surgical drainage is usually reserved for patients with gas-forming iliopsoas abscess and acute neurologic compression. In conclusion, we report a case of penetration of IVC filter into the lumbar disc space causing spondylodiscitis and iliopsoas abscess that was treated with percutaneous drainage and antibiotic therapy.
REFERENCES 1. Zhou D, Moon E, Bullen J, Sands M, Levitin A, Wang W. Penetration of celect inferior vena cava filters: retrospective review of CT scans in 265 patients. AJR Am J Roentgenol 2014; 202:643–647. 2. Dinglasan LA, Trerotola SO, Shlansky-Goldberg RD, Mondschein J, Stavropoulos SW. Removal of fractured inferior vena cava filters: feasibility and outcomes. J Vasc Interv Radiol 2012; 23:181–187. 3. Rana MA, Gloviczki P, Kalra M, Bjarnason H, Huang Y, Fleming MD. Open surgical removal of retained and dislodged inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2015; 3:201–206. 4. Hsieh MS, Huang SC, Loh el-W, et al. Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study. BMC Infect Dis 2013; 13:578.
Control of Inferior Epigastric Arterial Bleeding with Percutaneous Suture and Thrombin Injection after Coil Embolization Failure
Gnerre et al
’
JVIR
thrombin injection and full-thickness abdominal wall suturing. This case report did not require review and approval by our institutional review board. A 61-year-old woman with a history of alcoholic liver cirrhosis (Model for End-stage Liver Disease score of 31) was admitted from the emergency department for decompensated cirrhosis with hepatic encephalopathy and acute kidney injury. Anemia developed in the patient during the course of her hospitalization. Despite multiple blood transfusions, her hemoglobin level decreased from 11.6 g/dL at admission to a nadir of 5.1 mg/dL on hospital day 20. She was transferred to the medical intensive care unit for close monitoring. In the medical intensive care unit, her condition became hemodynamically unstable, with a hemoglobin level of 4.7 mg/dL, heart rate of 143 beats per minute, and blood pressure of 86/43 mm Hg. Vasopressor support and large-volume transfusion of blood products were initiated. On hospital day 21, a computed tomographic (CT) angiogram of the abdomen and pelvis demonstrated active hemorrhage from the right IEA (Fig 1). She was taken emergently to the interventional suite, and, under general anesthesia, a right external iliac arteriogram demonstrated an actively bleeding right IEA branch (Fig 2a). The skin overlying the bleeding site was marked and determined to be the site of daily subcutaneous enoxaparin injections; given the thin body wall, this was likely the inciting event. The right IEA was selected. Glue embolization was considered; however, the procedure was performed emergently after hours by a single operator. The bleeding site was embolized above and below the site of bleeding with 3-mm and 5-mm pushable feathered microcoils (Cook, Bloomington, Indiana; Fig 2b).
From: Jeffrey Gnerre, MD Marc Michael D. Lim, MD Shekher Maddineni, MD Department of Radiology Westchester Medical Center 100 Woods Rd. Valhalla, NY 10595
Editor: Inferior epigastric artery (IEA) injury is a complication of abdominal wall surgery, trauma, or interventional procedures (1–3). Patients with end-stage liver disease who present with hemorrhagic ascites as a result of IEA injury frequently have a superimposed coagulopathy (2). We describe a patient with end-stage liver disease and coagulopathy with life-threatening bleeding of the right IEA that was refractory to coil embolization and successfully treated with a combination of percutaneous None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.05.013
Figure 1. Axial arterial-phase CT image of the midabdomen demonstrates hemoperitoneum with active extravasation originating from a branch of the right IEA (circle).
Volume 27
’
Number 11
’
November
’
2016
1733
Figure 2. (a) Selective catheter-based arteriogram of the right external iliac artery before embolization demonstrates active extravasation (arrow) originating from a branch of the right IEA. The right IEA was selected and embolized above and below the site of bleeding with 3-mm and 5-mm coils. (b) Early arterial-phase image obtained immediately after coil embolization demonstrates residual flow within the right IEA (blue arrow) extending to the site of bleeding (yellow arrow). Additional coil embolization of the right IEA to its origin was performed, and a subsequent subtraction angiogram (c) does not demonstrate continued active extravasation of contrast medium.
Figure 3. Axial image from a CT angiogram of the abdomen and pelvis demonstrates metallic coils (red arrow) in the right IEA with adjacent active extravasation from a lateral branch (white arrow). There is a subjacent hematoma, as well as largevolume ascites, which displace bowel (asterisks) away from the bleeding vessel.
A subsequent arteriogram demonstrated persistent bleeding from the embolized IEA branch (Fig 2b). Coil embolization of the right IEA was continued to its origin to ensure that all potentially feeding branch vessels were embolized. A postembolization angiogram demonstrated
no evidence of continued active extravasation of contrast medium (Fig 2c). Immediately following the procedure, the patient’s blood pressure (112–131/48–75 mm Hg) and heart rate (69–88 beats per minute) stabilized. However, after 24 hours, her condition again became hemodynamically unstable, with a hemoglobin decrease to 6.8 mg/ dL, requiring blood product transfusion. A repeat CT angiogram obtained 48 hours after the initial embolization demonstrated continued bleeding from the same right IEA branch (Fig 3). She was returned to the interventional suite, and, under CT fluoroscopy, a 22-gauge spinal needle was inserted into the area of the bleeding, localized by using coils as a landmark. A total of 400 U of thrombin (1,000 U/mL; King Pharmaceutical; Bristol, Tennessee) was injected. Three percutaneous size 0 nylon sutures (Ethicon, Somerville, New Jersey) were then placed through the skin, rectus musculature, and fascia of the abdominal wall above and below the site of the bleeding. During the next 24 hours, the patient’s hemoglobin level stabilized to her usual baseline level of approximately 10.5 mg/dL without the need for continued transfusion, and vasopressor support was discontinued. Eight days after the second embolization, her condition stabilized sufficiently for transfer from the medical intensive care unit to the general floor. The patient died 16 days after the second intervention after developing acute respiratory decompensation with refractory shock secondary to liver failure. Spitzer et al (4) described five patients with IEA injury who were successfully treated with percutaneous
1734
’
Special Letters Section
transabdominal sutures. However, these were placed under laparoscopic guidance. The combination of percutaneous thrombin injection with full-thickness abdominal wall sutures has not been previously described to our knowledge. In the present case, it is difficult to determine with certainty whether occlusion was ultimately achieved as a result of the thrombin, sutures, or the combination thereof. Additionally, initial occlusion of the IEA and branching vessels may have been unsuccessful, necessitating further intervention. The most concerning potential complication of our proposed treatment is bowel injury from closed placement of abdominal wall sutures. In the present case, the large-volume ascites displaced bowel posteriorly. Additionally, cutaneous necrosis is a consideration in placement of transabdominal sutures (4). However, with superficial vessels like the IEA, collateral vasculature to the skin and muscle minimizes this risk. In conclusion, percutaneous thrombin injection in combination with full-thickness abdominal wall suturing provides a novel and minimally invasive treatment for IEA injury. With appropriate planning, this may be an additional line of treatment in patients with coagulopathy or whose condition is refractory to coil embolization.
REFERENCES 1. Georgiadis GS, Souftas VD, Papas TT, Lazarides MK, Prassopoulos P. Inferior epigastric artery false aneurysms: review of the literature and case report. Eur J Vasc Endovasc Surg 2007; 33:182–186. 2. Sobkin PR, Bloom AI, Wilson MW, et al. Massive abdominal wall hemorrhage from injury to the inferior epigastric artery: a retrospective review. J Vasc Interv Radiol 2008; 19:327–332. 3. Yalamanchili S, Harvey S, Friedman A, Shams J, Silberzweig J. Transarterial embolization for inferior epigastric artery injury. Vasc Endovasc Surg 2008; 42:489–493. 4. Spitzer M, Golden P, Rehwaldt L, Benjamin F. Repair of laparoscopic injury to abdominal wall arteries complicated by cutaneous necrosis. J Am Assoc Gynecol Laparosc 1996; 3:449–452.
Staged Particle and Ethanol Embolotherapy of a Symptomatic Pancreatic Arteriovenous Malformation
Frenk et al
’
JVIR
Care, Department of Surgery (T.E.C., P.J.F.) and Division of Nephrology, Department of Medicine (J.C.) Massachusetts General Hospital Harvard Medical School, 55 Fruit St. Boston, MA 02119
Editor: Pancreatic arteriovenous malformations (AVMs) are rare. Although sometimes asymptomatic, many present with abdominal pain, gastrointestinal bleeding, or pancreatitis (1). This letter describes a pancreatic AVM treated with staged embolization with particles and absolute ethanol. This case report was exempted from institutional review board approval. A 54-year-old man presented with necrotizing pancreatitis. Computed tomography (CT) demonstrated an AVM in the pancreatic head and body (Fig 1). The patient underwent transgastric endoscopic pancreatic necrosectomy via an Axios stent (Xlumena, Mountain View, California) and was discharged home. One week later, he was readmitted with hemorrhagic shock from hematemesis and hematochezia. An angiogram obtained under general anesthesia identified branches from the transverse pancreatic, left gastric, splenic, and replaced right hepatic arteries supplying the AVM (Fig 2). Given the patient’s hemodynamic instability and the complexity of the AVM, the dominant supplying artery was targeted for particle embolization to stabilize the patient’s condition emergently. One branch arising from the transverse pancreatic artery was catheterized with a Renegade HIFLO microcatheter (Boston Scientific, Marlborough, Massachusetts), and embolization was performed with 500–700-μm and 700–900-μm tris-acryl gelatin microspheres (BioSphere, Roissy, France) and Gelfoam (Pharmacia and Upjohn, Kalamazoo, Michigan). The patient’s condition stabilized. After discussion in a multidisciplinary meeting, the decision was made to embolize the other supplying arteries with absolute ethanol in a staged approach. In a second procedure under general anesthesia, after assessing the flow pattern and estimating the required volume with test hand-injections, a branch from the left
From: Nathan E. Frenk, MD Tiffany E. Chao, MD, MPH Jie Cui, MD Peter J. Fagenholz, MD Zubin Irani, MD Division of Interventional Radiology, Department of Radiology (N.E.F., Z.I.) Division of Trauma, Emergency Surgery and Surgical Critical
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.06.015
Figure 1. Axial contrast-enhanced CT shows the conglomerate of abnormal vessels in the pancreatic body (dashed outline). Surrounding inflammatory changes from pancreatitis (arrows) are also seen.