Transcatheter

Occlusion

of the Arterial

Supply

with Gianturco Downloaded from www.ajronline.org by 117.255.242.98 on 11/09/15 from IP address 117.255.242.98. Copyright ARRS. For personal use only; all rights reserved

THOMAS

A.

LAYNE,1’2

ETHEL

J.

AND

WILLIAM

with

a negative

from

right

the left hypogastnic

right tric

femoral

Case

Received

January

Department

4, 1978; accepted

of Radiology,

was

after revision

resected

131 :1027-1030,

© 1978 American

Roentgen

December Ray Society

August

County-University

90033. Address reprint requests to E. J. Finck. 2 Present address: 7 Gneenbnien Drive. Missoula. Am J Roentgenol

was

catheterized,

the aortic

coils

were

artery and

bifurcation placed

the

vein,

with

(fig. 2A). The catheter

was

into the left hypogas-

in the

hypogastnic

artery.

follow-up. 3

cause in 1971 in Mexico. In addition, the patient had been taking digoxin and Lasix for valvular heart disease for 4 years. Physical examination revealed a widened pulse pressure,

artery

Los Angeles

Two

to the corresponding

P. 5. , a 55-year-old female, had hematunia and dysunia for 4 days. Medical history revealed a mastectomy for unknown

bounding distal pulses, systolic and diastolic murmurs compatible with mitral stenosis and mitral regurgitation, bilateral basiIan rales, and a palpable left lower quadrant abdominal mass with a bruit and thrill.

and

Chest

re-

1978

Montana

radiography

showed

marked

cardiomegaly

and

in-

creased pulmonary vasculanity with cephalic redistribution. Excretony unography revealed delayed and markedly decreased left renal function. Provisional diagnosis was valvular heart disease, with high output failure secondary to probable renal arteniovenous fistula. At angiography, a large renal arteniove-

placed with a graft from the left saphenous vein. Numerous smaller injuries to the profunda femoris were repaired. Venous bleeders were tied oft. The patient recovered and was discharged without symptoms. However, at a clinic visit 3 weeks after surgery, a loud machinerylike bruit was heard over the right thigh. Percutaneous angiography revealed multiple arteniovenous fistulas involving the profunda femoris artery and vein. Retrograde flow was noted in many veins, as well as a large pseudoaneurysm of the profunda femoris artery (fig. 1A). Since no single fistulous communication was found at sungery, the angiographers embolized the pnofunda femonis artery. Two Gianturco coils were placed in the artery at the level of the pseudoaneurysm. Angiography performed immediately after embolization showed occlusion of the artery and nonfilling of the pseudoaneurysm and arteniovenous fistuias. The patient had mild fever to 38.4#{176}C for 24 hr after embolization. He did not

I

artery

around

artery.

9-month

Reports

femoral

artery

of the hypogastnic

Angiography immediately after embolization demonstrated complete occlusion of the fistula and pseudoaneurysm (fig. 28). The patient developed a slight fever (37.9#{176}C), which returned to normal 48 hr after embolization. He was discharged 3 weeks after embolization, and had no further complaints during the

male, was shot in the right groin with a He presented in hemorrhagic shock and repair of severe arterial and venous in-

superficial

examination.

a large pseudoaneurysm

1

The

physical

J. S. , a 63-year-old man, was beaten and had a broomstick inserted into his rectum during a robbery. He presented in shock with massive rectal bleeding. At surgery, a 16 cm laceration of the rectum was found. No definite injury of a major vessel was identified. The patient bled several times after removal of the rectal packing. Angiography revealed an arteniovenous fistula

Preoperative transcatheter occlusion of the arterial supof various abdominal tumors using Gianturco stainless steel coils with wool strands is becoming more common [1]. Use of these coils in experimentally created arteriovenous fistulas in dogs and in two cases of human renal arteriovenous fistulas was recently described [2, 3]. In the humans, the coils were placed in the fistulas from the venous side. This report describes our experience using these coils to occlude the feeding artery to arteriovenous fistuias.

jury.

BOSWELL1

2

Case

ply

A. C., a 16-year-old single shotgun blast. underwent immediate

D.

complain of pain nor exhibit other symptoms. Repeat angiography 2 months later again showed no arteniovenous communication (fig. 1B). After 10 months the patient is asymptomatic,

manipulated

Case

Fistulas

Coils

FINCK,1

Transcatheter occlusive therapy Is finding widespread dInIcal application. Numerous types of occlusive devices have been described. This report details the first three cases of occlusion of the arterial supply to arteriovenous fistulas with Glanturco stainless steel coils. Patients benefiting from this approach include those who refuse or cannot tolerate surgery, those In whom previous surgery failed, and those with chronic fistulas In whom surgery Is likely to fall. The anglographer should make sure the coil Is completely within the desired vessel, the feeding vessel Is smaller than the coil to prevent passage through the fistula, and there is adequate collateral flow to distal organs to prevent infarction after occlusion of a major artery. This technique Is useful as a nonsurgical treatment for a variety of arterlovenous flstulas and Is within the capabIlity of any experienced angiographer.

Case

to Arteriovenous

nous

patient

fistula

with

refused

a huge

draining

surgery.

While

vein

was found

recognizing

(fig.

potential

3A).

The

complica-

tions of renal embolization, in this instance nonsurgical occlusion of the main feeding artery was considered the best treatment of the fistula. It was hoped that leaving the smaller feeding artery patent would supply blood to the small amount of residual functioning renal tissue. Prior to embolization, the cardiac output measured 10.2 I/mm

by

the

method.

cardiogreen

Two

Gianturco

coils

were

inserted into the left main renal artery and the patient showed immediate clinical improvement. Cardiac output dropped to 5.2 I/mm, pulse from 104 to 65 beats/mm, and blood pressure from 160/90 to 1 10/58. Aortography at placement of the coils showed

22, 1978. of Southern

California

Medical

Center,

1200

North

State

Street,

Los Angeles,

California

59801.

1027

0361

-803X/78/1

200-1

027

$00.00

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1028

LAYNE

ET

AL.

Fig . 1 . - Case 1 , femorab arteniograms. A, Early arterial phase demonstrating arrow)

large pseudoaneurysm of profunda femonis

Note opacification indicating

(open artery.

of numerous

veins

arteniovenous shunting arrows). B, Occlusion of pro-

(closed funda femonis 2 months after embolization . Pseudoaneunysm is occluded and there is no evidence of arteniovenous

shunting.

Fig. 2.-Case 2. midartenial phase arteriograms. A, Internal iliac vein drains early (closed arrow) and there is a large pseudoaneurysm (open arrow) of hypogastnic artery. B. Two coils in hypogastnic artery; arteniovenous fistula is closed. Clot has propagated proximally to artery origin.

complete occlusion of the main feeding the large draining vein (fig. 3B). Immediately

after

embolization,

the

artery

without

patient

filling

developed

of mild

nausea and vomiting. She had chills and fever to 38.1#{176}C.All symptoms had disappeared at 48 hr. , and she was discharged after 5 days. Cardiac status showed continuing improvement. Murmurs were no longer present and echocandiognaphy demonstrated a normal mitral valve. Murmurs heard on admission

recently,

Anderson

wire

coils

dogs. nous

Wallace fistulas

via

a venous

closure Gelfoam. edge,

of the

approach.

first

turco-Wallace-Anderson

arteniovenous

been

fistula

has

lost not

to

follow-up.

been

Exact

cause

of

the

determined.

Discussion Transcatheter

vascular

clinical indications [5, 7-10] has been reviewed

the

various

materials

1 the

exposed

occlusive

[4-8] using described.

3 were

In case therapy

for

various

a wide variety of materials In 1976 Grace et al. [11] and

techniques.

More

lab,

at surgery.

using

demonstrated some ment

steam

and

use

catheterized

of the

are, coils

to conform

to the

on preembolization

slight difficulty was because the catheter

using knowl-

angiograms.

the

the

Gian-

set.

Cases

approach. in the

preformed

vascular

experienced was inserted

reported

using

directly

were

[7]

to occlude

via a transfemoral

The catheters

in

arteriovesegment

fistulae to our

embolization

placed

of

fistulas

Cubillo

fistulas. carried out

was

placing

treating two in the fistulous

arterial

catheter

the

arteriovenous

Stanley

supply to arteriovenous embolizations were

2 and

described

of arteriovenous case reports

to describe

to

has

[2]

created

two cases The present

arterial The

and

al.

et al. [3] reported by placing the coils

were believed to be caused by the high flow rate across the valve, rather than to organic disease. The hematunia and dysunia were resolved at discharge. Unfortunately, the patient returned Mexico

et

in surgically

vessel

in our

anatomy,

as

In case

in catheter placein the left hypo-

2

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TRANSCATHETER

OCCLUSION

OF

ARTERIOVENOUS

FISTULAS

1029

Fig. 3.-Case 3. A, Aortogram showing tangled mass of fistubous vessels in lower pole of left kidney. Note huge draining vein (arrows). B, Postembolization arteniogram demonstrating occlusion of artery and absence of large draining vein. Distal coil (arrows) was considerably larger than artery, preventing complete coiling.

gastric

artery

from

with

a hooked and a guide

catheter bifurcation cation

and

down

the

into

right

side.

curve wire the

Initially,

left

hypogastric.

the visceral catheter was exchanged tion catheter inserted. No difficulty inserting any of the coils. It should

be emphasized

a visceral

was placed over inserted around

that

profunda

femoris

and

to the

remaining

occlusion

hypogastric

inadequate

organ

or

or

than

the

the

artery

the

an size

artery

of

supplying

the

risk

coil

heart

coil

and

of

respec-

flow

infarcting

coil

or than the

venous

could

occur.

slightly

the

size

of the

draining coil

vein

artery,

with

simultaneous

a wire

snare

has

prevent

into the main venous circulation. In each of our three cases, clot propagated

and

retrograde

fashion

along

the

occluded

closest major branch of the artery there were no major branches). reported that coils placed so that either into the arterial or the venous caused the

thrombosis

fistula.

been placed saved, and artery

vessel.

must

beyond the coil

to avoid

Clot

of the

Care

vessel

in a to

or

vein,

to make

in addition sure

the

to

coil

has

also

a nidus

form

of clot

in the

within

arteriovenous

the

parent

fistula

will has

that the and

that the

This

did

since

the

possibility

reopen the not occurred

surgery

single

the

instances fistula of

the

artery, and

is not that

embolization

alternative, long-term

arteriovenous

and relief.

on

by

ob-

fistulas

may

placement

be

communications

obliteration may

of

possible. are

may be inaccessible, coil into the fistula.

surgery

coil exists

artery is applicable in a variety of of fistulas. If an arteriovenous fistula

itself the

occur

be followed for for patients who tolerate surgery,

has failed,

communication,

fistula

not

fistula at some future in two of our patients

be the only may offer

occluding feeding types

plished

of the

multiple

preventing By occluding

fistula

a

coil

However,

can

in or the direct the

be accom-

be avoided.

ACKNOWLEDGMENTS We thank Ellen Duncan ance with this manuscript.

the

(or to the origin, if Anderson et al. [2] a portion protruded side from the fistula

Gelfoam.

fistula,

in whom

feeding

of the

any major branches that should be must be entirely within the desired

forming

could

artery

be taken

actual insertion

loss of the rapidly

feel

one

many

to be

catheterization

could

for those

We

itself,

artery

the

of the feeding artery may the basis of our experience

within

embolized should be carefully measured using arteriography before inserting the coil. If any doubt exists about the

and

than

circulation

with

be emphasized

within

structing locations

larger

fistula

The

is

strongly

is smaller

it must

pulmonary circulation. Stanthis complication in one of

at 9 and 10 months, patients should recurrence of symptoms. However, refuse surgery, for those who cannot

a vital

be

be

If the

into

lungs

to vital around

must

should

fistula

supply-

supply flow

If collateral

extremity

the

of the

to the

the

entire

of the

arteries,

Finally, actually

into the reported

embolized

collateral flow time. While this

large arteries. In case left patent to provide

tissue.

to be occluded.

embolization even

marginal,

even

considered. Ideally,

renal

two patients in our series.

and the embolizawas encountered in

tively, permitted sacrifice of these 3 a smaller feeding branch was blood

itself and embolize ley and Cubillo [7]

aortic bifur-

Subsequently

ing artery must not compromise the blood tissues. In cases 1 and 2 adequate collateral the

the the

and

Marie

Adnianos

for their

assist-

REFERENCES Goldstein HM, Wallace S, Anderson JH, Bree AL, Gianturco C: Transcatheter occlusion of abdominal tumors. Radiology 120:539-545, 1976 2. Anderson JH, Wallace 5, Gianturco C: Transcatheten intravascular coil occlusion of experimental arteriovenous fistulas. Am J Roentgenol 129:795-798, 1977 3. Wallace S, Giantunco C, Anderson JH, Goldstein HM, Davis JL, Bree AL: Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. Am J Roentgenol 127:381-387, 1976 1

.

1030

LAYNE

4. Doppman bolization

JL, DiChiro G, Ommaya AY: Percutaneous of spinal cord arteniovenous malformations. Neurosurg 34:48-55, 1971 5. Kerber C: Experimental arteniovenous fistula creation

percutaneous

10:10-17,

vestRadiol

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catheter

6. Luessenhop

obstruction

with

cyanoacrylate

arterial

AJ, Spence

embolization.

J

and .

In-

1975

WT: Artificial

embolization

ebral arteries: report of a case of arteniovenous tion.JAMA 172:1153-1155, 1960 7. Stanley AJ, Cubillo E: Nonsurgical treatment

nous malformations

em-

of the trunk Radiology

of cermalforma-

of arteniove-

and limb by transcatheter 115:609-612, 1975

ET

AL. 8. Robles venous

C, Carrasco-Zanini

J: Treatment

of cerebral

antenio-

malformations by muscle embolization. J Neurosurg 29:603-608, 1968 9. Kricheffll, Madayag M, Braunstein P: Transfemonal catheter embolization of cerebral and posterior fossa arteriovenous malformations. Radiology 1 03 : 1 07-1 1 1 , 1972 10. Gianturco C, Anderson JH, Wallace 5: Mechanical devices for arterial occlusion. Am J Roentgenol 124:428-435, 1975 11. Grace DM, Pitt DF, Gold RE: Vascular embolization and occlusion by angiographic techniques as an aid or alternative to operation . Surg Gynecol Obstet 1 43 : 469-482, 1976