Detachable coil embolisation for iatrogenic femoral arteriovenous fistula in patients with CHDs

We present two cases of patients with iatrogenic femoral arteriovenous fistula who underwent successful embolisation using three-dimensional shape detachable coils. A 49-year-old male with Tetralogy of Fallot had arteriovenous fistula which developed from the common femoral artery to the femoral vein with an aneurysm and a 17-year-old female with single ventricle after total-cavo-pulmonary-connection had two arteriovenous fistulas which developed from the internal iliac artery to the femoral vein. A total of six and seven pieces of detachable coils were necessary for complete occlusion, respectively. No complications were recorded. The advantage of the detachable coil is a wide variation and repositioning until the coil achieves good stabilisation and an ideal configuration.

Abstract 128: RNA-seq Based Non-Invasive Endovascular Biopsy of Brain Arteriovenous Malformations

Introduction: To-date, there is no accurate means to identify which bAVMs will bleed and treatment remains controversial. Hypothesis: We developed an endovascular biopsy (EB) technique to isolate endothelial cells (ECs) from bAVMs in patients. We hypothesized this technique would allow RNA-seq analysis of relevant bAVM-related molecular pathways. Methods: EB was performed during angiography for bAVM patients undergoing resection. Cells were obtained from a bAVM juxta-nidal feeding artery and iliac artery (control) with a detachable coil and 0.035 inch wire. ECs were isolated with fluorescence assisted cell sorting (FACS). bAVM tissue was obtained from surgery, dissociated and underwent FACS sorting. Total RNA extraction and library preparation was performed, and samples sequenced on an Illumina HiSeq 4000 sequencer. Reads were aligned with Kallisto, and differentially expressed genes identified between bAVM and control with Sleuth using likelihood ratio tests. Correlations between EB and resected tissues were calculated with Pearson correlation coefficients. Principle Component Analysis (PCA) was used to assess for cell clustering. Results: EB was performed in 4 patients without complication or adverse event. PCA showed separation of bAVM ECs from controls. Analysis demonstrated 106 differentially expressed genes (FDR p ≤ 0.05). KEGG pathway analysis on these genes revealed enrichment in bAVM-related RAS/MAPK cell signaling functionally related to trophic factor, chemokine and gap junction signaling pathways. Detected genes were strongly correlated between EB and ECs isolated from resected tissues (R 2 = 0.77 for artery, nidus, and vein tissue). Results shown in Figure 1 . Conclusions: EB is a safe technique to permit non-invasive sequencing of bAVMs. These results implicate dysregulated KRAS/MAPK signaling in adult bAVMs. Whether this technique will allow for better natural history prediction or targeted medical therapies requires future study.

P1001Safety and effectiveness of transcatheter leak occlusion with detachable coils following left atrial appendage closure

Introduction Incomplete left atrial appendage (LAA) closure resulting in residual, significant leak is common after LAA exclusion procedures, potentially hindering an effective thromboembolic (TE) prevention. Detachable coils have found a wide range of applications for transcatheter vascular occlusion/embolization procedures. Purpose We report for the first time the feasibility and efficacy of transcatheter leak closure with detachable coils in patients with incomplete LAA closure. Methods Thirtyconsecutive high TE-riskpatients with a clinically-relevant residual leak (mean age: 72±9 years; 73.3% males; CHA2DS2-VASc: 4.3±1.5; HAS-BLED: 3.4±1.1)underwent percutaneous closure of the LAA patency via detachable coils (Interlock-35 Fibered IDC Occlusion System, Boston Scientific Inc.; Concerto Helix Detachable Coil System, ev3 Endovascular Inc; Azur Embolization System, Terumo Interventional Systems). Trans-oesophageal echocardiography (TEE) was performed at 45±15 days post-procedure to assess for residual LAA patency. Results LAA closure had been previously attempted with a Watchman device in 25 patients, an Amulet in 2 and a LARIAT in 3. At pre-procedural TEE, a moderate/severe leak was documented in 28 (93.3%) patients, a mild one in 2 (6.7%) patients. Procedure andfluoroscopy times were 73±40min and 21±15min, respectively; the mean volume of iodinated contrast medium was 80±48mL. Overall, 114 coils were released into patents' LAA (median: 3 coils/patient; IQR: 2–4). Coil deployment was successful in 98.2% of cases (112/114). The overall complication-free rate was 93.3% (28/30). There were no instances of vascular injury, TE events, device dislodgment. There was 1 major adverse device-related event in an 87-yo male, who developed pericardial tamponade requiring a pericardial window. A small pericardial effusion without hemodynamic compromise was noted in a 78-yo woman and treated conservatively. Follow-up TEE in all patients revealed complete LAA sealing or a minimal-mild leak in 28 cases (93.3%; 22 with no residual leak, 6 with a minimal-mild residual one), and a moderate residual leak in 2 patients (6.7%). Conclusions Transcatheter LAA leak occlusion via detachable coils is a safe, effective and promising approach in high TE-risk patients with incomplete LAA closure.

Flow-directed micro-catheterisation technique over a detachable coil

Embolisation of neonatal arteriovenous shunts poses several challenges: tortuous and fragile vessels, limited contrast volume and few specialised paediatric endovascular devices. In a 9-day-old patient with a choroidal type vein of Galen malformation we encountered an extremely tortuous posterior choroidal artery pedicle during endovascular treatment. After attempted selection using a traditional over-the-wire technique, we advanced a platinum coil through the micro-catheter. High flow within the feeder directed the soft and malleable coil anterograde. We then advanced the catheter over the coil’s pusher wire in a facile manner to an ideal position for embolisation. This approach may be especially useful in cases requiring coil/vinyl-based liquid embolics, given that the only flow-directed micro-catheter available to most operators is compatible with n-Butyl cyanoacrylate alone. Moreover, the soft distal portion of coil may impart a safety benefit over traditional guidewires in easily perforated neonatal vasculature.

Medina embolization device for the treatment of intracranial aneurysms: 18 months’ angiographic results

Background and purposeThe Medina embolization device (MED) is a new flow disruption device combining the design of a detachable coil with an intrasaccular flow disrupter. Safety and short-term angiographic effectiveness of this device have recently been reported. However, long-term angiographic results are lacking. We report herein the 18 months’ angiographic outcome in patients treated for a wide-neck intracranial aneurysm with the MED.Materials and methodsNineteen patients (17 female, mean age 50 years) with 20 wide-neck intracranial aneurysms (six ruptured; 14 unruptured) were treated by the MED between January 2015 and June 2016. Procedure-related complications were systematically recorded; discharge and 6–9 months' follow-up modified Rankin Scale scores were assessed. Angiographic mid-term and long-term follow-up were performed with a mean delay of 6.4±1.5 months (n=16 aneurysms) and 17.7±4.2 months (n=15 aneurysms), respectively. Occlusion rates were evaluated after the procedure and at the mid-term and long-term follow-up using the Roy-Raymond scale.ResultsEmbolization with the MED was feasible in all except two cases (2/20, 10%). One per-procedural perforation was recorded (1/20, 5%) and one MED deployment failed because of the aneurysm’s shape (1/20, 5%). Three cases of thromboembolic complications were observed (3/20, 15%). Only one thromboembolic complication was responsible for clinical sequelae. Grade A occlusion rate was 61% (11/18) after the procedure, 75% at 6 months' follow-up (12/16), and 80% (12/15) at long-term follow-up. Two cases (2/18, 11%) of recanalization at mid-term were documented angiographically. No recanalization occurred between the mid-term and long-term follow-up.ConclusionMED is a hybrid embolization device, combining properties of a conventional coil with those of an intrasaccular flow disrupter. Our series focusing on long-term angiographic follow-up shows a satisfactory long-term occlusion rate. Larger series with longer angiographic follow-up times are warranted to confirm these preliminary results.

Endovascular treatment for pelvic congestion syndrome associated with inferior vena cava anomaly

Introduction: Pelvic congestion syndrome is described as chronic pelvic pain arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence and pelvic pain is not established. Embolization appears to provide symptomatic relief in the majority of women and is safe. Case report: We report the case of a young woman affected by pelvic congestion syndrome associated with a rare venous anomaly, duplicity of inferior vena cava with azygos vein continuation. Endovascular treatment consisted of detachable coil embolization of the right ovarian vein, as pelvic pain was prevalently on this side. Technical and clinical outcome were positive with a significant improvement of quality of life. Conclusion: This is the first reported case of a pelvic congestion syndrome associated with inferior vena cava anomaly and effectively treated with ovarian vein embolization.