Percutaneous angiographic embolization: A procedure of increasing usefulness

SCIENTIFIC PAPERS

Percutaneous Angiographic Embolization: Increasing Usefulness

Review of a Decade of Experience

A Procedure of

Frederick S. Keller, MD, Portland, Oregon Josef Rosch, MD, Portland, Oregon Gerald M. Baur, MD, Portland, Oregon Lloyd M. Taylor, MD, Portland, Oregon C. T. Dotter, MD, portland, Oregon John M. Porter, MD, portland, Oregon

Deliberate , percutaneous , therapeut ic vascular occlusion by selective ifijection of embolic subs tances through angiographic ca theters was first p e r f o r m e d by Newton and 'Adams [I] in 1967. In the past d e c a d e a t the Univers i ty of Oregon Hea l th Sciences Cente r we pe r fo rme d 152 selective t r ansca the te r embol iza- t ions in 124 pa t ien t s for a wide range of clinical p rob lems (Table I). T h e p r ima ry indicat ion for angiographic vasooc'clusion was control of acute or recurrent bleeding. Other indications included closure of ar ter iovenous fistulas, occlusion of congenital ar- ter iovenous ma l fo rma t ions and cavernous h e m a n - giomas, devascularizat ion Of renal and bone tumors , and abla t ion of renal function. Our exper ience is re- viewed herein.

Material and Methods

Patients were referred for transcatheter vasoocclusion after thorough evaluation of their clinical status and other possible therapeutic alternatives by the attending surgical and medical staffs and by the angiography division. Twenty-fi;ce of the 124 patients underwent embolization for upper gastrointestinal hemorrhage from arterial sources and 32 patients had transhepatic occlusion of bleeding varices. Infarction was done in 31 primary renal carcinomas and 1 squamous cell metastasis to the kidney associated with hematuria and severe pain. Transcatheter ablation of renal function Was done in three patients with chronic renal failure who had either uncontrollable hypertension or severe urinary protein loss. Selective hemostatic embolization was performed in one patient with massive he-

From the Department of Diagnostic Radiology, Division of Vascular Surgery, University of Orego n Health Sciences Center, School of Medicine, Portland, Oregon. This work was supported in part by the George Alfred Cook Memorial through the Medical Research Foundation of Oregon, Portland, Oregon, and by Genera! Clinical Research Center Grant RR-00334.

Requests for reprints should be addressed to Frederick S. Keller, M D, Department of D!agnostic Radiology, University of Oregon Health Sciences Center, School of Medicine, 3181 S.W. Sam Jackson Park Road, Portland, Oregon 97201.

presented at "~he 52nd Annual Meeting of the Pacific Coast Surgical As- sociation, Coronado, California, February 15-18, 1981.

maturia after biopsy. Another patient with traumatic hematuria had selective occlusion of an intrarenal arterial branch feeding a moderate-sized pseudoaneurysm. Eight patients with congenital arteriovenous malformations in various locations underwent a total of 21 vasoocclusive procedures. Extensive soft tissue cavernous hemangiomas were embolized in four patients. Pelvic arteries supplying either primary or metastatic tumors involving the pelvic bones were occluded in four patients. Pelvic vessels responsible for severe hemorrhage due to trauma (four patients), after surgery (one patient), and secondary to advanced gynecologic malignancy (two patients) were embolized. Sixteen congenital pulmonary arteriovenous fistulas in one patient who had previously undergone bilateral pulmonary lobectomy were closed in five procedures, and solitary, systemic iatrogenic arteriovenous fistulas were obliterated in three others. Two patients with massive hemoptysis underwent bronchial artery embolization; another patient with postoperative hemobilia had occlusion of a distal branch of the right hepatic artery which fed a prominent pseudoaneurysm.

Procedures were performed by staff angiographers or experienced angiography trainees under direct staff su- pervision. Embolic material employed included autologous blood clot (2 procedures), surgical gelatin (Gelfoam ®, 41 procedures), microfibrillar collagen (Avitene ®, 3 procedures), polyvinyl alcohol (Ivalon ®, 5 procedures), isobutyl-2-cyanoacrylate (bucrylate, 24 procedures), Gianturco stainless steel coil steel coil spring occluders (24 procedures) or combinations of these materials (53 procedures).

The choice of embolic material or device was based on specific anatomic features and on whether the vascular occlusion was to be temporary or permanent and proximal or peripheral. In arteriovenous fistulas or malformations and renal carcinomas, the size of the individual arteriovenous communications and the velocity of blood flow through the lesion were also important technical factors influencing the Selection of the vasoocclusive material or method used.

Diagnostic angiography always preceded vasoocclusion; in emergency situations, therapeutic embolization was

Volume 142, July 1981 5

Keller et al

Figure 1. Selective left gastric angiograms In a patient with active bleeding from a Mal- tory-Weiss tear in a large hiatal hernia before ( A) and after ( B ) embolization with Gelfoam powder. A, the branches of the left gastric artery extend above the diaphragm indicating a hlatal hernia. Direct extrava- satlon (arrow) Is present into the hernia at the site of the Mallory-Weiss tear. B, after embollzation, the smaller peripheral branches of the left gastric arteries were occluded and there was no longer ex- travasation.

often done as an extension of the diagnostic procedure. Whenever possible, however, the therapeutic procedure was separated from the diagnostic study to permit the patient to recover and to allow more time for planning the embolization. In large lesions with multiple feeders, several sittings were often required for adequate vasoocclusion in order to avoid overloading the patient with contrast material and the risk of acute renal failure. Of the 120 arterial embolizations, 115 were performed from the femoral ap- proach and the remaining 5 by the transaxillary route. Venous embolization of the left gastric and short gastric veins and gastroesophageal varices in patients with variceal

TABLE I Number of Patients and Embolization Procedures According to Clinical Problems

Embolization Patients procedures

Clinical Problems (n) (~ :,:~; ~

Arterial upper gastrointestinal bleeding 25 26 Variceal upper gastrointestinal bleeding 32 36 Renal carcinoma

Nonresectable 24 26 Resectable 7 7

Kidney metastasis 1 1 Traumatic and postbiopsy hematurla 2 2 Renal ablation 3 4 Congenital arteriovenous malformations 8 21 Cavernous hemangiomas 4 5 Pelvic hemorrhage

Traumatic 4 4 Tumor 2 2 Postoperative 1 1

Pelvic bone tumors 4 5 Pulmonary arteriovenous fistulas 1 5" latrogenic arteriovenous fistulas 3 3 Hemoptysis 2 3 Hemobilia 1 1

Total 124 152

* Sixteen separate pulmonary arteriovenous fistulas were closed in this patient.

hemorrhage was done through the transhepatic ap- • proach.

Results

Arterial Upper Gastrointestinal Bleeding

Twenty-five patients underwent 26 embolizations for acute upper gastrointestinal bleeding from arterial sources [2]. One patient was treated on two separate occasions 10 days apart for acute bleeding from different lesions, with control of hemorrhage both times. Upper gastrointestinal endoscopy was performed before therapeutic angiography in most instances. The left gastric artery was embolized in 19 patients for bleeding from either stress ulcers, Mal- lory-Weiss tears {Figure 1), erosive gastritis or gastric ulcers; the gastroduodenal artery or its branches, or both, were embolized in seven patients for bleeding duodenal ulcers. Autologous blood clot was used in two early patients and Gelfoam, either as small pieces or powder, or coil spring occluders were used in the other patients. Bleeding was controlled in 23 (92 percent) of the 25 patients. One therapeutic failure was the exsanguination of a patient with a severe coagulopathy and massive bleeding from an ulcer in a large hiatal hernia. The other patient whose hemorrhage was not controlled by embolization underwent successful emergency surgery for a giant duodenal ulcer. Gastric ischemia, the only significant complication of embolization in this group of patients, occurred i n a massively traumatized patient who a few days earlier had undergone surgical ligation of major collateral arteries to the stomach. Twenty-one (84 percent) of 25 patients with uncontrollable upper gastrointestinal hemorrhage, most of whom were considered high risk surgical candidates~ left the hospital alive. Four patients (16 percent) died from their underlying medical problem. There were no procedure-related deaths.

6 The American Journal of Surgery

Percutaneous Angiographic Embolization

Variceal Hemorrhage

Selective transhepatic occlusion of the left gastric and short gastric veins and gastroesophageal varices was at tempted in 32 patients [3]. Successful transhepatic portal catheterization with obliteration of the varices and their feeders was achieved in 30 patients (94 percent) (Figure 2.) In one patient we were unable to enter the portal system due to a marked anatomic distortion of its intrahepatic branches; in our other unsuccessful attempt, we could not completely occlude an extremely large left gastric vein with rapid flow and direct shunting into the azygous system. Eighteen patients underwent emergency variceal embolization while actively bleeding; 8 of them were hemodynamically unstable. Fifteen patients treated

on an emergency basis were in Child's class C, and the other 3 had Child's class B cirrhosis. All 18 patients with acute bleeding were considered unacceptable surgical risks. Elective variceal embolization was done in 12 patients, usually within 24 to 48 hours of a major bleeding episode. Three patients who had elective variceal embolization were in Child's class A; three were in class B, and the remaining six were in class C. Only 4 of our 12 electively embolized patients were considered good candidates for porto- systemic shunting.

Active variceal bleeding was initially controlled in 15 (83 percent) of the patients with acute hemorrhage. On average, 12 units of blood were given to each of the 18 patients with acute bleeding during the episode immediately preceding variceal obliteration,

Figure 2. Control ( A ) and post- variceal embolization follow-up ( B) transhepatic porlograms in a patient with bleeding gastroesophageal varices. A, a prominent coronary vein (arrow) feeds gastroesophageal varlces (ar- rowheads) in the control study. The left liver lobe is hypertrophied and has a prominent left portal venous branch ( LPV). B, there is no filling of the gastroesophageal varices and coronary vein after their occlusion.


Keller et al

while only 3 units were given to each of only 3 patients who required transfusions after the procedure.

Combining both groups (emergency plus elective embolizati0ns), 23 (77 percent) of the 30 successfully embolized patients did not have rebleeding from varices during follow-up of I to 32 months (for over I year in 18 patients). Five patients had subsequent upper gastrointestinal bleeding which on endoscopy proved arterial rather than variceal in origin. Two others had recurrent upper gastrointestinal bleeding clinically thought, but not endoscopically proven, to be variceal. Five patients had rebleeding from varices.

Significant complications of variceal embolization included renal failure (one patient), peritonitis (one patient), hemopneumothorax (one patient), portal vein thrombosis (partial, one patient; complete, one patient) and hemoperitoneum not requiring surgery (two patients). The sole procedural fatality occurred in an actively bleeding, semicomatose patient who aspirated a large volume of gastric contents during the procedure.

Renal Embolization Renal carcinoma: Thirty-one infarctions were

performed in patients with renal carcinoma [4]. In 24 (77 percent) of these patients the tumor was unresectable and palliative embolization was done to relieve hematuria or severe pain, or both, and to re- duce tumor bulk in conjunction with chemotherapy (Figure 3). In 19 of the 24 patients with unresectable tumors, hematuria requiring transfusions was the

main indication for embolization. Bleeding was controlled in all such instances. Five others had relief of severe pain. Two of them had metastatic disease and died 4 and 7 months after embolization. The other three patients in this group were lost to follow-up.

Seven patients with resectable malignancies, most of which were extremely vascular tumors, underwent preoperative embolization to decrease surgical blood loss and facilitate operation. The average blood loss during surgery in 'the seven patients who had preoperative renal infarction was 900 ml. One of these patients had temporary resolution of pulmonary metastases after successive tumor infarction, nephrectomy and chemotherapy.

Renal metastases: In one patient with hematuria and severe pain due to a biopsy-proven renal metastasis from recurrent squamous cell lung carcinoma, relief of symptoms was achieved by renal infarction [5].

Renal ablation: Three patients with chronic renal failure and severe hypertension (one) or proteinuria (two) were referred for "catheter nephrectomy" [6]. Immediately after renal infarction all three became anuric. In the patient with previously uncontrollable hypertension after bilateral renal infarction, blood pressure was maintained at acceptable levels with a significant reduction in antihypertensive medica- tion.

Renal trauma: Massive hematuria in two patients (one after trauma, the other after biopsy) was controlled by selective vasoocclusion of the intrarenal branch responsible for bleeding [7].

Figure 3. Selective left renal angiogram before (A) and after ( B) left renal infarction In a patient, with a large unre- seclable renal carcinoma. A, the control angiogram demon- strates typical hypervascular tumor vessels of a renal carcinoma. There is early filling of the left renal vein. B, after peripheral tumor embulization with Gelfoam pieces and proxima ! occlusion with a sfalnless steel coil spring oc- cluder (arrowhead), there is essentially no flow to the tumor.



A typical syndrome of fever, leukocytosis, pain and occasionally ileus developed after infarction of the kidneys with large neoplasms. Mild to moderate flank pain only occurred in patients with chronic renal failure who had catheter nephrectomy and in the patients who had selective occlusion of more peripheral intrarenal branches. There were no deaths or significant procedure-related complications in this group of patients.

Congenital Arteriovenous Malformations

Eight patients with congenital arteriovenous malformations underwent a total of 21 vasoocclusive procedures [8]. Two patients had small intrarenal arteriovenous malformations that were producing recurrent eposides of gross hematuria. These lesions were easily selectively embolized (one procedure each) with preservation of a maximal amount of renal tissue. Neither patient had further bleeding. The remaining six arteriovenous malformations were large, complex lesions with multiple arterial feeders. Three involved the pelvis, two the buttocks, and one the neck and face. The number of embolizations required to palliate or obliterate these arteriovenous malformations attests to the high degree of difficulty in eradicating such lesions by angiographic vasoocclusion. One patient with a cardiac output of 18 liters/min due to shunting of blood through a massive pelvic arteriovenous malformation underwent 10 separate vasoocclusive procedures. The cardiac output gradually decreased after each procedure and remained at 7.5 liters/min during the year after the last embolization. One large pelvic arteriovenous malformation requiring two embolizations appeared

completely obliterated on follow-up angiograms 3 months after vasoocclusive therapy, with no evidence of recurrence during a 12 month follow-up period. In three patients vasoocclusion, although incomplete, led to a significant reduction in the size of and blood flow through the arteriovenous malformations after embolization; however, these lesions were not completely obliterated, and future enlargement of the residual central vascular nidus seems likely. In one patient with a large pelvic arteriovenous malformation, angiography after three separate embolizations revealed persistence of the lesion despite permanent occlusion of the original feeding arteries and part of its nidus. In complex systemic arteriovenous real- formations, new arterial feeders tend to develop after otherwise encouraging therapeutic occlusions.

Significant complications in the foregoing patients included pulmonary embolization of both angiographic embolic material and bland thrombus from massively enlarged pelvic veins (one patient), small areas of skin slough or necrosis (two patients), foot drop due to occlusion of the vasa nervorum of the sciatic nerve (one patient) and a "catheter sympa- thectomy" producing warmth and increased blood flow to the affected leg in one patient after embolization of the middle and lateral sacral arteries.

Cavernous Hemangiomas Four patients had therapeutic embolization of

cutaneous and large subcutaneous hemangiomas [9]. Two involved the face and neck, one the left leg and the other the chest wall. The latter hemangioma has recurred twice after attempted surgical excision. All of these lesions appeared to have been effectively eradicated by embolization. A minor skin slough re-

Figure 4. Aortograms before ( A ) and after ( B) closure of a large right renal artery- to.renal-vein fistula after nephrectomy. A, there is enlargement of the right renal artery and prompt opacification of the Inferior vena cava. B, after occlusion of the right renal artery with stainless steel coil spring occluders, there is no flow through the fistula.


Keller et al

quiring split-thickness grafting occurred in the patient with the leg hemangioma. Extensive plastic surgical repair of a major slough was needed in one of the patients with a facial lesion.

Pelvic EmbolizaUon

Eleven patients had embolization of the pelvic arteries. Acute hemorrhage aftermassive trauma was controlled by embolization of branches of the hypogastric arteries in four patients, as was vaginal bleeding due to advanced gynecologic malignancy in two patients [6,10]. One elderly patient had bilateral hypogastric embolization for severe hemorrhage after attempts to remove surgical drains following a su- prapubic prostatectomy. Before embolization he required 40 units of blood; after it none was needed.

The blood supply to four tumor s involving the ilium (three) and pubis (one) was occluded [11]. The iliac tumors (fibrosarcoma, chondrosarcoma and metastatic thyroid) were embolized to palliate severe pain previously unresponsive to chemotherapy or irradiation. Symptomatic relief was obtained in two of these three patients. The pubic tumor, an extensive aneurysmal bone cyst which bled profusely during open biopsy, had destroyed the entire right superior pubic ramus in a 14 year old girl. Six months after embolization a major soft tissue component of this tumor was no longer evident and the previously

destroyed pubic ramus had been replaced by dense cortical new bone. No significant procedure-related complications occurred in this group of patients.

Arteriovenous Fistulas

Pulmonary: In a 34 year old patient who presented with recurring cerebral abscesses, 16 pulmonary arteriovenous fistulas were closed percuta- neously over the course of five separate vasoocclusive procedures [12]. The patient had previously undergone bilateral pulmonary lobectomies to little avail. After selective transcatheter occlusion of most of the numerous persisting fistulas, right to left intrapul- monary shunting decreased from 30 to 8 percent of the cardiac output. Although she is not cured, in addition to the marked hemodynamic improvement, she has had no recurrence of cerebral abscess in the 8 months since embolization. Follow-up will be continued.

Iatrogenic: Three patients with iatrogenic arteriovenous fistulas, two of them postsurgical, underwent fistula closure by transcatheter techniques [13]. A large postnephrectomy right renal artery-to-renal vein fistula with a calculated flow rate of 1,200 ml/ min was responsible for high output failure in a 54 year old patient. The fistula was successfully closed (Figure 4). A splenic arteriovenous fistula complicated splenectomy done as part of a Sugiura procedure and contributed to refractory variceal hemor-

Figure 5. Selective hepatic angiograms in a 10 year old patient with recurrent episodes of upper gastrointestinal hemorrhage. A, a prominent pseu. doaneurysm is being fed by an enlarged peripheral branch (arrowhead) of the right hepatic artery, B, 2 months after superselective obliteration of the pseudoaneurysm, the feeding branch has returned to normal size and the pseudoaneurysm does not fill.



rhage. That fistula was closed in conjunction with variceal embolization. Portal venous pressure mea- sured just before closure of the fistula was 36 mm Hg and decreased to 17 mm Hg afterward. Follow-up celiac angiography 9 months later demonstrated lasting occlusion of the fistula. Rebleeding has not occurred during a 27 month follow-up.

Successful closure of an internal mammary artery-to-innominate vein fistula complicating subclavian central venous pressure catheter insertion was also achieved. Angiography 3 months afterward revealed persistent obliteration of the fistula.

No complications occurred during, or as a result of, closure of these fistulas. Two patients (with renal artery-to-renal vein and internal mammary artery- to-innominate vein fistulas) required less than i day of hospitalization.

Hemoptysis Two patients with recurrent massive hemoptysis

had therapeutic bronchial artery embolization [I4]. In one, a severely debilitated 16 year old, acute hemorrhage complicating cystic fibrosis was controlled. Although no further bleeding occurred, the patient died from the primary disease 3 weeks later. The other patient, a 32 year old Oriental man with recurrent hemoptysis from long-standing inactive tuberculosis of the right upper lobe, underwent attempted right upper lobectomy. Massive hemorrhage accompanying chest wall entry forced termination of the operation. Subsequently, the patient had embolization of large bronchial and intercostal arteries feeding the diseased portions of the lung, In a second session, several large branches of the right subclavian artery which supplied the chest wall and, through it, the chronically inflamed lung, were occluded. Before embolization this patient had received transfusions of 42 units of blood; after it, he required no transfusions.

Hemobilia A 10 year old girl who had four episodes of upper

gastrointestinal hemorrhage during the 6 weeks after surgical repair of a traumatic liver laceration was angiographically shown to have a prominent pseudoaneurysm in the right liver lobe (Figure 5A). The diagnostic catheter was advanced peripherally into and used to occlude the arterial branch which fed the lesion [15]. The procedure was uneventful and the patient was discharged the next morning. Angiog- raphy 2 months later revealed persistent obliteration of the pseudoaneurysm (Figure 5B), and she has had no further bleeding during a 17 month follow-up.

Summary

During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions

in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of thera- Peutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

References

1. Newton TH, Adams JE. Angiographic demonstration and nonsurgical embolization of spinal cord angioma. Radiology 1968;91:873-6.

2. RSsch J, Dotter CT, Brown MJ. Selective arterial embolization: a new method for control of acute gastrointestinal bleeding. Radiology 1972;102:303-6.

3. Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med 1974; 291:646-9.

4. Goldstein HM, Wallace S, Anderson JH, Bree RL, and Gianturc C. Transcatheter occlusion of abdominal tumors. Radiology 1976; 120:539-45.

5. Mariasoosai M, Wilson A, Gonick P. Selective renal artery embolization: treatment for metastatic sarcoma with hematuria. JAMA 1977;237:363-4.

6. Dotter CT, Goldman ML, RSsch J. Instant selective arterial occlusion with Isobutyl 2-Cyanoacrylate. Radiology 1975; 114:227-230.

7. Richman SD, Green WM, Kroll R, Casarella WJ. Superselective transcatheter embolization of traumatic renal hemorrhage. AJR 1977;128:843-4.

8. Joyce PF, Sundaram M, Riaz A, Wolverson MK, Barner HB, • Hoffman RJ. Embolization of extensive peripheral angio-

dysplasias: the alternative to radical surgery. Arch Surg 1980;115:665-8.

9. Cunningham DS, Paletta FX. Control of arteriovenous fistulae in massive facial hemangioma by muscle emboli. Plast Reconstr Surg 1979;46:305-8.

10. Ring EG, Athanasoulis C, Waltman AC, Margolies MN, Baum S. Arteriographic management of hemorrhage following pelvic fracture. Radiology 1973;109:65-70.

11. Wallace S, Granmayeh M, De Santos LA, et al. Arterial occlusion of pelvic bone tumors. Cancer 1979;43:322-8.

12. Taylor BG, Cockerill EM, Manfredi F, Klatte EC. Therapeutic embolization of the pulmonary artery in pulmonary arteriovenous fistula. Am J Med 1978;64:360-5.

13. Castaneda-Zuniga WR, Tadavarthy M, Murphy W, Beranek I, Amplatz K. Nonsurgical closure of large arteriovenous fistulas. JAMA 1976;236:2649-50.

14. Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977;122:33-7.

15. Heimbach DM, Ferguson GS, Harley JD. Treatment of traumatic hemobilia with angiographic embolization. J Trauma 1978;18:221-4.


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D i s c u s s i o n

William W. K r i p p a e h n e (Portland, OR): This is a remarkable and diverse group of patients. Embolization was accomplished with extremely low morbidity and mortality and very good therapeutic results.

In superficial gastric erosion, extensive gastritis and Mallory-Weiss bleeding, the use of Gelfoam occlusion avoids major operation with its higher morbidity and mortality and at the same time allows recanalization of arteries with little or no permanent vascular insufficiency. It has been less time-consuming and more efficacious than either intravenous or selective intraarterial vasopressin, which were used in our institution before the occlusion techniques. It seems somewhat less dependent on an intact coagulation system. In major arterial bleeding from deep penetrating ulcers, either gastric or duodenal, it has been more effective than vasopressin.

Patients with massive hemorrhage from esophageal varices have been initially much more readily treated by occlusion and have had an initial mortality rate that is a fraction that of shunt surgery. Whether there will be significant prolongation of life in the survivors, significantly decreased late rebleeding and less late encephalopathy remain to be studied. The complications of this occlusive therapy were much higher in this group of bleeders than in the arterial group, but I would expect them to decrease with more experience.

I will not comment extensively on renal embolization for carcinoma. I expect an unpredictable but definite incidence of sepsis and abscess, even with antibiotics, in major infarctions. One patient with splenic infarction developed splenic abscesses and died from infection.

The treatment of arteriovenous malformations has been the most intriguing of all of the problems presented. There has been a distinct learning curve in their treatment. Ini- tially, we embolized a patient with Gelfoam and occluded some major branches with springs without occluding the peripheral shunt. It was not efficacious as it was merely followed by increased flow from other feeder vessels and occluded the easiest access to obliterating the peripheral shunt. It was no better than surgical ligation of the major arteries. Fine grated Ivalon went to smaller branches but again, did not occlude the peripheral shunts. It remained for the development of timed polymerization of cyanoacrylate as devised by Kerber to effectively occlude the peripheral shunts.

A young Chinese girl, first seen in 1976, had a very large arteriovenous anomaly. This was fed from branches of both hypogastric arteries as well as from the inferior mesenteric, middle sacral, fourth and fifth lumbar, and bilateral superficial and deep femoral arteries. The cardiac index was 19. After initial large vessel occlusion, the portion between skin and gluteal musculature was excised between occluding ligatures at a cost of 30 units of blood and skin closure obtained. It reulcerated 6 months later. Further embolization with finely grated Ivalon occluded small branches leading to the arteriovenous fistulas.

Timed polymerization of cyanoacrylate resins finally occluded the anomaly at the peripheral site where neces- sary. Six major embolizations reduced the cardiac index to 7:9. We reclosed the ulceration the second time during 1980. The patient still has significant fistulas fed from both the superficial and deep femoral systems. As we came closer

to our major decrease in blood supply we moved more slowly, attempting to avoid major complications of major tissue infarctions. We have had complications of temporary sciatic paresis with foot drop, pain, sepsis and slough of the ulcerated area, uterine bleeding and irregular menses. Whenever we remove compression from the buttocks, the area tends to further ulcerate and break down centrally. Further embolization is planned.

It may seem like a long and complicated course, but the alternatives were sepsis, massive bleeding and high output failure or hemicorpectomy. This problem is as devastating as uncontrolled cancer. The overall palliation has been worthwhile.

R o b e r t W. Rand (Los Angeles, CA): The authors have beautifully demonstrated various techniques and uses of embolization in the treatment of a variety of conditions and diseases. I used a similar technique since 1970, employing ferrosilicon as the agent. This is injected in a liquid form and then vulcanizes by catalyst action once it is placed in the desired region under fluoroscopic control. In one patient ferrosilicon was selectively embolized into a hyper- nephroma. Ischemic necrosis occurred except for some cancer cells at the periphery. Therefore, we added hysteresis heating to the embolization procedure to destroy these residual cancer cells.

This thermomagnetic surgery is accomplished by a powerful alternating Litz coil system. The microparticles of iron oscillate to produce heat by friction, that is, hysteresis. This prototype coil system has been tested at the Jet Propulsion Laboratory and will soon be installed at UCLA Hospital. When a ferrite is substituted for the pure carbonyl spherical iron microparticles, it will heat by hysteresis. The kidneys of dogs have been totally destroyed by this combination of ischemic and hysteresis necrosis. This also occurred in a rabbit VX2 carcinoma model pro- duced in the kidney.

I congratulate the authors for their fine presentation of a subject that is rapidly becoming more acceptable to the medical community.

L y m a n A. Brewer , I I I (Loma Linda, CA): The control of upper gastrointestinal hemorrhage in 19 of 20 cases is impressive. The authors report successful bronchial artery embolization for hemoptysis. There is an extensive experience with this technique in France, where cord paralysis has been an awesome complication. This was brought about by the inconstant and fragile blood supply of the spinal cord. The anterior spinal artery may have no collateral vessels and be totally dependent on segmental end artery branches of the intercostal vessels. Especially vul- nerable are branches supplying the area of the cord between the sixth and eighth thoracic vertebrae, frequent sources of the bronchial arteries. Often the spinal branch artery comes off with or may be a branch of the bronchial artery, so that embolization may produce ischemia of the spinal cord. After bronchial arteriography has been com- pleted, if the branch to the anterior spinal artery fills, embolizagion should be abandoned. If the spinal branch does not fill at the time of initial angiography, the balloon of the Fogarty catheter should be inflated and a careful neurologic examination be made. Any neurologic changes that are detected at this juncture should contraindicate embolization of the bronchial artery.

We believe a safer method of managing exigent he-



moptysis is the transbronchial catheterization of the segmental bronchus responsible for bleeding with a Fogarty catheter inserted through a fiberoptic bronchoscope. The balloon of the catheter is then blown up and tamponade of the bronchus occurs. In 15 of 16 cases so treated at the USC Medical Center, hemoptysis was controlled.

We believe the Fogarty catheter balloon technique to be a successful alternative to bronchial arterial embolization, particularly when the principal danger in exigent hemoptysis is aspirated blood, which produces progressive as- phyxia. Death is not caused by exsanguination in most cases. This is particularly true in the patient with a com- promised pulmonary function. Nevertheless, the authors are to be congratulated for bringing to our attention the successful employment of percutaneous transcatheter embolization, not only to control exigent hemorrhage in various sites in the body, but also .for use in other pathologic states.

Robert W. Jamplis (Palo Alto, CA): I showed the ab- stract of this report to our radiologist and angiographer, Joseph Walter, who has been doing this procedure for many years at the Palo Alto Clinic and Stanford Univer- sity. He pointed out that Dr. RSsch published the first report on this subject and that the Portland group is the foremost in the world using this technique.

We have done the procedure in 60 patients and it has been of tremendous help. First, it can turn a difficult procedure into an easy one, and also make it much safer for the patient. Second, it can obviate an operation where otherwise the surgeon might be forced into operating, with possible disastrous results.

My partner, Walter Cannon, recently had a patient with a large vascular mediastinal tumor and, after giving several bottles of blood and making little progress, he wisely de- cided to back out. Dr. Walter was able to catheterize the large bronchial artery feeding the tumor and embolize it. Dr. Cannon was then able to safely and easily resect the tumor.

The following case illustrates how this technique can be definitive treatment rather than subjecting the patient to what might be extremely difficult surgery. A 48 year old woman had two very severe hematemeses from demonstrated huge esophageal varices, presumably from long- standing nonalcoholic cirrhosis. At age 2 she had had a bypass (ileotransverse colostomy) for Crohn's disease. She had lived 45 years with few symptoms, although a small bowel study showed residual disease in the small bowel and the colon. However, because she had had severe bleeding, a portal system shunting procedure was being contem- plated. Dr. Walter was asked to demonstrate the venous phase of the angiogram to determine what procedure to use. However, in catheterizing and injecting the superior mesenteric artery, he was surprised to find that in the arterial phase the portal vein showed up as welt as did the superior mesenteric vein, which led right into the region of the Crohn's disease in the ileum. Obviously, there was an arteriovenous fistula in the area (presumably from the old operation on the disease), which might have been the cause of the cirrhosis. To catheterize such an artery, one must be exceedingly skillful, and care must be exercised not to cause infarction as these are end arteries. A small aliquot of Ivalon sponge and Gelfoam was used for embolization, resulting in obliteration of the fistula. This was done 8 months ago. The patient has had no further bleed-

ing, and the varices are now about half the size they were.

Leon Morgenstern (Los Angeles, CA): I would like to ask two brief questions. Since isobutyl-cyanoacrylate polymerizes rapidly in the presence of moisture, how do you get it to the target site without premature polymerization? Second, it is my impression that isobutyl-cyanoacrylate is not FDA-approved for clinical use. Is this method of vascular occlusion still an experimental protocol or has it now been approved for the uses described here?

John M. Por ter (closing): This remarkable group of patients represents one of the largest, if not the largest, group, of patients so treated to date, and the experience extends over 11 years at the University of Oregon.

The initial procedure was reserved for desperate situations where the risk of surgery appeared unacceptably high. This ~ is not true at present. It is obvious the procedure is applicable to certain situations in which conventional surgery has no role, such as diffuse pulmonary arteriovenous fistula, postbiopsy renal arteriovenous fistula and extensive diffuse congenital arteriovenous malformations involving large sections of the body and bleeding from tumors. Whether or not this procedure will prove durable in the treatment of upper gastrointestinal arterial or variceal bleeding remains to be seen, but there is no denying the benefit of converting an unstable emergency operative patient to a stable elective one.

One point of considerable importance and interest to me is just who should be performing these procedures. The complex choices between balloon occlusion, spring wire occlusion, cyanoacrylate, Gelfoam, and so on require great skill and experience, and clearly every angiographer should not be expected to be facile with this procedure, just as he should not be expected to be an automatic expert on the now famous, or infamous, procedure of transluminal an- giop!asty.

Dr. Krippaehne asked about abscess in the patients with organ infarction. To date this has not been a problem. These patients all received broad spectrum systemic antibiotics, and a rather typical syndrome of flank pain and fever for several days has been present, but to date no abscess has been seen.

We are impressed with Dr. Rand's description of his vulcanizing ferrosilicon technique with thermohysteresis. This is a dynamic field with many changes occurring almost daily. One method under investigation at our institution is the injection of absolute alcohol in an attempt to control tumor growth.

Dr. Brewer raised a very cogent question about the possibility of spinal cord ischemia as a complication of this procedure. At present whenever bronchial embolization is to be performed, an extraordinarily careful fluoroscopic examination is conducted in an effort to visualize spinal cord blood flow, and also temporary balloon occlusion is used before bronchial embolization. If that produces any symptoms, the procedure is not carried out. It remains to be seen whether or not we will see spinal cord ischemia in the future.

Dr. Morgenstern, the polymerization is controlled by fractional mixing with Pantopaque ®. The degree of mixing determines the speed of polymerization. The material has not been released for general market use, and it requires an investigation by the FDA.


Documents

Percutaneous angiographic embolization: A procedure of increasing usefulness