To evaluate the clinical effectiveness and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for pseudoaneurysms complicating pancreatitis or pancreatectomy.
Twelve procedures were performed in nine patients (seven men and two women; mean age, 60.6 years) for pseudoaneurysms that occurred secondary to pancreatitis or as a consequence of pancreatic juice leakage at the site of pancreatectomy. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1-1:4; in one patient with failed selective catheterization of the target vessel, the mixture ratio was 1:9. Technical and clinical success rates, recurrent bleeding, procedural complications, serum amylase level, and clinical outcome were determined for each procedure.
Embolization was technically successful in all procedures, with no recurrent bleeding documented from the initially treated territory. In three procedures, we encountered additional bleeding vessels at 11, 33, and 49 days after the procedures, which were successfully managed by a second embolization in each case. There were no major complications related to the procedures. As minor complications, in two procedures, the embolized material overflowed beyond the target vessels; however, no clinically significant ischemic events were observed in the embolized territories. Serum amylase did not increase compared with initial levels after any of the procedures. Seven patients were discharged after clinical improvement. Two patients died 2 and 3 weeks after the embolization as a result of multiple organ failure not associated with the procedure.
In this limited series, NBCA embolization was found to be feasible and effective for pseudoaneurysms as a complication of pancreatitis or pancreatectomy.
"MDCTAo is especially useful for detecting hemorrhage in the region of the pancreatic head and for identifying arterial supply from the celiac artery and/or superior mesenteric artery (Figures 3 and 4) (Izaki et al. ). Furthermore, although overlapping with other contrast-stained organs causes difficulties in identifying extravasation of CM in angiography, MDCTAo resolves this problem (Figures 3, 4 and 5). "
[Show abstract][Hide abstract] ABSTRACT: Aortography for detecting hemorrhage is limited when determining the catheter treatment strategy because the artery responsible for hemorrhage commonly overlaps organs and non-responsible arteries. Selective catheterization of untargeted arteries would result in repeated arteriography, large volumes of contrast medium, and extended time. A volume-rendered hemorrhage-responsible arteriogram created with 64 multidetector-row CT (64MDCT) during aortography (MDCTAo) can be used both for hemorrhage mapping and catheter navigation. The MDCTAo depicted hemorrhage in 61 of 71 cases of suspected acute arterial bleeding treated at our institute in the last 3 years. Complete hemostasis by embolization was achieved in all cases. The hemorrhage-responsible arteriogram was used for navigation during catheterization, thus assisting successful embolization. Hemorrhage was not visualized in the remaining 10 patients, of whom 6 had a pseudoaneurysm in a visceral artery; 1 with urinary bladder bleeding and 1 with chest wall hemorrhage had gaze tamponade; and 1 with urinary bladder hemorrhage and 1 with uterine hemorrhage had spastic arteries. Six patients with pseudoaneurysm underwent preventive embolization and the other 4 patients were managed by watchful observation. MDCTAo has the advantage of depicting the arteries responsible for hemoptysis, whether from the bronchial arteries or other systemic arteries, in a single scan. MDCTAo is particularly useful for identifying the source of acute arterial bleeding in the pancreatic arcade area, which is supplied by both the celiac and superior mesenteric arteries. In a case of pelvic hemorrhage, MDCTAo identified the responsible artery from among numerous overlapping visceral arteries that branched from the internal iliac arteries. In conclusion, a hemorrhage-responsible arteriogram created by 64MDCT immediately before catheterization is useful for deciding the catheter treatment strategy for acute arterial bleeding.
"Permanent occlusion of small or tortuous vascular branches and multiple collateral sources may also be accomplished using liquid embolic agents such as N-butyl cyanoacrylate (NBCA; TRUFILL Liquid Embolic System, Cordis Neurovascular, Miami Lakes, FL, USA), and ethylene vinyl alcohol copolymer (Onyx; ev3, Plymouth, MN, USA). These materials have the advantage of low viscosity, allowing a single injection to simultaneously fill numerous downstream vascular channels before polymerizing into a hard cast (8). In an analysis of 12 patients treated with liquid embolic agents for pseudoaneurysms related to pancreatitis or pancreatectomy, Izaki et al. (8) reported a technical success rate of 100%, no recurrent bleeding, and no major complications. "
[Show abstract][Hide abstract] ABSTRACT: Major vascular complications related to pancreatitis can cause life-threatening hemorrhage and have to be dealt with as an emergency, utilizing a multidisciplinary approach of angiography, endoscopy or surgery. These may occur secondary to direct vascular injuries, which result in the formation of splanchnic pseudoaneurysms, gastrointestinal etiologies such as peptic ulcer disease and gastroesophageal varices, and post-operative bleeding related to pancreatic surgery. In this review article, we discuss the pathophysiologic mechanisms, diagnostic modalities, and treatment of pancreatic vascular complications, with a focus on the role of minimally-invasive interventional therapies such as angioembolization, endovascular stenting, and ultrasound-guided percutaneous thrombin injection in their management.
Korean journal of radiology: official journal of the Korean Radiological Society 04/2012; 13 Suppl 1(Suppl 1):S45-55. DOI:10.3348/kjr.2012.13.S1.S45 · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study was designed to evaluate the safety of selective transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) in a swine model in terms of histological changes in the pancreas.
Three groups of two female swine (58-64 kg) per group underwent TAE of the dorsal pancreatic artery, under anesthesia, with 1:1, 1:4, and 1:9 mixtures of NBCA and iodized oil. Blood parameters were evaluated at days 1, 4, and 10 after TAE, after which the animals were sacrificed and pancreatic tissues were examined under light microscopy.
All of the animals were asymptomatic and survived for 10 days. Cone beam computed tomographic angiography revealed occlusion of the dorsal pancreatic artery and no enhancement in the embolized area. The white blood cell count and C-reactive protein level were elevated slightly on day 1 after TAE (mean ± SD: 252.7 ± 27.8 × 10(2)/μl and 0.15 ± 0.07 mg/l, respectively), but they normalized or remained near the upper normal limit thereafter. The serum amylase and lipase levels also were elevated on day 1 (8831.7 ± 2169.2 U/l and 130 ± 53.4 U/l, respectively) but normalized thereafter. Histologically, necrosis and fibrosis were noted only in the embolized segment, and necrosis and acute inflammatory reactions were absent in the nonembolized segment. The border between both segments was well defined. Lymphocytic infiltration and foreign body reaction were noted around the embolized vessels.
Selective TAE with NBCA in the pancreas caused localized ischemic necrosis without clinically significant pancreatitis; therefore, this procedure is tolerable in swine.
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