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405
Technical ..
,
...‘,.‘i
‘.
‘;.,
A Coaxial
Catheter
and
Embolize
Branches
of the Splanchnic
Masatoshi
Okazaki,1
Takayuki
Hideyuki
Higashihara,
Steerable Fumitaka
Guidewire
Koganemaru,
Used
to
Arteries Hiroyuki
Ono,
Toshio
Hoashi,
and
Kimura
Superselective catheterization of small branch arteries is a valuable technique for embolization therapy of hemorrhage and for other diagnostic and therapeutic purposes [1 ]. The
caliber of these vessels is often smaller than the 5.0-French angiographic catheters routinely used. A new highly nadiopaque and flexible coaxial infusion catheter has significantly simplified
superselective
catheterization
of these
small-caliber
arteries [2]. We report successful emergent superselective embolization for hemorrhage from various small-caliber splanchnic
Materials
artery
branches
with the coaxial
catheter.
and Methods
Emergent
embolization
procedures
with
the coaxial
catheter
sys-
tem were performed on 13 arteries in 1 0 patients. Of the 10 patients, hemorrhages in four involved the liver (two ruptured hepatocellular carcinoma and two hemobilia), two involved the small intestine, and the nemainingfoun involved to determine the bleeding
the stomach. After diagnostic angiography site, the tip of the 5.0-French preshaped
catheter (Cook Inc., Bloomington, IN) was inserted into the various arteries as an introducing catheter. A commercially available 3.0French, 150-cm Tracker-i 8 infusion catheter (Target Therapeutics, Inc., Mountain View, CA), which accepts a 0.41-mm steerable guidewine, was used as the inner coaxial catheter. The inner catheter was advanced through the introducer over the guidewire into many penipheral
Note
arterial
branches
2 mm or smaller
in diameter.
Gelfoam particles (Upjohn Co., Kalamazoo, Ml), ranging in size from 500 m to 1 mm, were used alone as embolic material in 10 arteries, Gelfoam particles plus Hilal embolization microcoils (Cook,
Inc., Bloomington,
des plus Ivalon
IN) were (Unipoint,
used
in two arteries,
and Gelfoam
artery. Embolic materials, loaded into a 2.5-mi small syringe containing iopamidol, were then injected through the Tracker catheter until there was stasis of flow on occlusion of the embolized arteries.
Results In seven cases, complete hemostasis was obtained by embolization with Gelfoam particles alone. In the two cases of hemobilia, the hepatic artery pseudoaneunysms were mitially embolized with Gelfoam particles. However, bleeding was not stopped completely in one, and rupture of a pseudoaneurysm neoccurred in the other. Additional embolization of a small-caliber hepatic artery branch with Ivalon (Fig. 1) and the Hilal embolization microcoils resulted in occlusion of the pseudoaneunysms and immediate cessation of bleeding. In one case of gastric bleeding from a gastric ulcer, the left gastric artery was initially embolized with Gelfoam particles, but complete hemostasis was not achieved. Additional embolization of the left gastric artery with the Hilal embolization microcoils was necessary to stop the hemorrhage permanently. In eight of these 1 0 cases, embolization was the definitive therapy and surgery was obviated. Elective partial resection of the ileum was performed in one patient with a bleeding Meckel diverticulum, and gastrectomy and partial resection of the jejunum were performed in one patient with a bleeding stomal ulcer after stabilization of the patient’s
Received January 5, 1990; accepted after revision March 13, 1990. This work was supported in part by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. I All authors: Department of Diagnostic Radiology, Fukuoka lkiiversity Hospital, 7-45-1 Nanakuma Jounart-ku Fukuoka, 81 4-01 Japan. Address
to M. Okazaki. AJR 155:405-406,
August
1990 0361-803X/90/1
552-0405
© American
parti-
Inc., High Point, NC) were used in one
Roentgen Ray Society
reprint requests
OKAZAKI
406
ET AL.
AJR:155,
August 1990
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Fig. 1.-Hemobilia caused by nipture of left hepatic artery pseudoaneurysm. A, Arteriogram of common hepatic artery shows pseudoaneurysm (arrow) in small-caliber left lateral inferior hepatic artery (arrowheads). B, Tracker-18 catheter advanced through introducing catheter into left lateral inferior hepatic artery. Arrow shows tip of Tracker catheter and arrowheads show percutaneous transhepatic biliary drainage tube in left lateral inferior biliary duct.
A
B
condition by hemostasis. The histologic findings on the resected specimens showed no ischemic change in the ileum and no jejunal infarction but did show mild mucosal inflammation with submucosal edema of the jejunum. All patients were later discharged from the hospital.
Discussion The smaller the vessel to be occluded, the greater the likelihood of success and the safety of the embolization procedure. Therefore, the ideal technique for achieving hemostasis requires that the catheter is selectively advanced as near as possible to the bleeding artery to be occluded [i 3]. Recently, a new commercially available 3.0-French coaxial catheter and a tapered 0.41 -mm platinum-tipped steerable guidewine have been used successfully to catheterize and embolize a small branch of the visceral artery [2, 4]. The flexible polyethylene tip and the semirigid proximal portion of the Tracker catheter allow some control of torque, so that it can be advanced past the tip of the introducing catheter without a guidewine and directly into peripheral branch vessels without accompanying trauma. Alternatively, the catheter can be advanced oven a 0.41 -mm steerable guidewine into a supenselective position. The platinum tip on the steerable guidewine and the platinum coil in the catheter tip allow easy fluonoscopic visualization of wire and catheter position. Furthermore, not only the Gelfoam particles but also a variety of small embolic agents, such as the Hilal embolization microcoils, have been injected through the catheter [5]. In our series, we were able to introduce the catheter into all the desired small branches superselectively, without subintimal injury on spasm. Matsumoto et al. [6] reported the first series of three patients with visceral arterial bleeding who were treated by supenselective Gelfoam embolization with this catheter. Inadvertent embolization of an uninvolved arterial branch occurned in one of the three patients because of overzealous injection, which can result in a high-pressure hydraulic jet that may lead to neflux of embolic material [6]. In the current cases, such a migration of Gelfoam into uninvolved vessels ,
was avoided by slow and careful injection of Gelfoam particles with a small syringe. The role of embolization in the management of small-bowel bleeding remains controversial, and relatively few cases have been reported [7, 8]. In this article, we describe two cases of small-bowel hemorrhage in which successful supenselective embolization, without the occurrence of bowel infarction, was performed with a Tracker catheter as the primary control; the absence of bowel infarction was later verified histologically in the nesected specimens [8]. We believe that this type of embolization has the potential for the greatest degree of effectiveness in control of bowel hemorrhage, with the least possible risk of bowel infarction. In our series, we found that this coaxial catheter system was highly reliable for achieving superselective catheter p0sitions in small-caliber arteries, minimizing the volume of infarcted tissue, and allowing maximal preservation of splanchnic organic function. We conclude that this system clearly represents a significant advance in interventional radiology.
REFERENCES 1 . Meyerovitz
MF, Levin DC, Boxt LM. Superselective catheterization of small-caliber arteries with a new high-visibility steerable guide wire. AJR 1985; 1 44: 785-786
2. Chuang VP. Superselective hepatic tumor embolisation catheter. J lntervent Radio! 1988;3:69-71 3. CoIdwell diology
DM.
Hepatic
embolization
with an open-ended
with Tracker-i guide
wire.
8 Ra-
1987;165:285-286
4. Orzel JA, Coldwell DM, Eskridge JM. Superselective hemorrhage with a new coaxial catheter vasc Intervent Radio! 1988:11:343-345
and steerable
embolization guidewire.
for renal Cardio-
5. Hilal 5K, Khandji AG, Chi TL, Stein BM, Bello JA, Silver AJ. Synthetic fibercoated platinum coils successfully used for the endovascular treatment of arteriovenous malformations, aneurysms and direct arteriovenous fistulas of the CNS (abstr). AJNR 1988;9:1030 6. Matsumoto AH, Suhocki PV, Barth KH. Superselective Gelfoam embolotherapy using a highly visible small caliber catheter. Cardiovasc Intervent Radio!
1988;1
1:303-306
7. Jander HP. Small bowel embolization. Radiology 1981;140:566-567 8. Okazaki M, Higashihara H, Yamasaki S. et al. Arterial embolization to control life-threatening hemorrhage from a Meckel’s diverticulum. AJR 1990;154: 1257-1258