Urgent Transcatheter Arterial Embolization for Wunderlich Syndrome With Hypovolemic Shock Secondary to Ruptured Renal Angiomyolipoma

Purpose: Wunderlich syndrome (WS) with hypovolemic shock secondary to ruptured renal angiomyolipoma (rAML) represents an urgent condition. Hence, we reported our experience with transcatheter arterial embolization (TAE) using different embolic materials under this condition.Methods: This retrospective study consisted of 22 patients. Embolic materials including particles, microcoils, and liquid embolic agents were selectively used based on the decisions of interventional radiologists. Technical success was defined as the complete occlusion of bleeding vessels on the final renal angiogram. Clinical success was defined as the absence of re-hemorrhage needed for repeat endovascular or surgery treatment after TAE.Results: The articulated materials were used when WS presented without aneurysms; a combination of particulate materials and microcoils or Glubran 2 alone were used for WS with aneurysms. The technical success based on 24 episodes of TAEs in 22 patients was 100% (24 of 24). Repeat TAE was achieved in two patients with hemorrhages re-occurring two days after the initial embolization with microcoils alone. The clinical success was 90.9% (20 of 22). No nontarget embolization or embolization-related complications occurred during the TAE procedure. Of the patients, 27.3% (6 of 22) experienced minor complications of post-embolization syndrome (PES). During a median follow-up time of 34 months, no recurrent hemorrhage that required repeat endovascular or surgical treatment for hemostasis occurred.Conclusion: Urgent TAE with the selective use of different embolic materials is an effective alternative to control WS with hypovolemic shock secondary to ruptured rAML. The condition of presenting with or without aneurysms may determine the embolic materials employed.

Penile Glans Necrosis following Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia: A Rare but Serious Complication

Background. Prostate artery embolization (PAE) is a novel endovascular procedure to treat men with benign prostatic hyperplasia (BPH) symptoms who wish to maintain sexual potency postoperatively. However, serious treatment-related adverse events (TRAEs) of PAE such as penile glans necrosis (PGN) can be devastating and require urgent attention. Case presentation. Mr GM is a 65-year-old sexually active Anglo-Saxon man who have long-standing BPH symptoms unresponsive to medical therapy. While he had an uneventful bilateral superselective PAE using gel foam, there were signs to suggest of PGN, and this was treated conservatively. The patient presented to the emergency department 5 days later with a painful, dark penile glans and accompanying urinary dysuria and hematuria. Clinical examination confirmed evolving PGN. He received 10 courses of hyperbaric oxygen therapy (HBOT) with complete resolution of his PGN. Conclusion. While superselective embolization is usually always performed, nontarget embolization may occur, as intravascular particles may reflux into adjacent vessels. In this unique and extremely rare case report of PGN following PAE, complete resolution was achieved with HBOT. Proposed benefits of HBOT include anti-inflammation, promotion of neovascularization, and induced rate of collagen deposition, resulting in a faster and more effective resolution of PGN.

Selective Arterial Embolizations of Renal Angiomyolipomas Using 96% Ethanol: A Case Series of 5 Patients

Angiomyolipomas are rare benign tumors of the kidneys, with a risk of spontaneous hemorrhage including severe retroperitoneal bleedings. In this study, we report clinical outcomes of 5 patients who underwent 8 embolization sessions using 96% ethanol, as there is scarce data using this embolic agent for this indication. The primary angiographic success could be achieved in all but 1 lesion, which was not accessible due to vasospasm of the supplying vessel. Therapeutic success could be demonstrated in all treated cases for which follow-up imaging was available (n = 3). In 1 complex patient, a mildly reduced renal function, as well as a new onset of arterial hypertension was detected after treatment. Nontarget embolization of vital kidney tissue was demonstrated in another patient; it remained asymptomatic. Embolization therapy using 96% ethanol is an optional method to treat renal angiomyolipomas.

Anterior Cord Syndrome after Embolization for Malignant Hemoptysis

Interventional radiology plays an integral role in the management of massive and recurrent submassive hemoptysis. Risks of bronchial artery embolization (BAE) are well described and include spinal ischemia and paralysis, most often related to nontarget embolization of the artery of Adamkiewicz or other large radiculomedullary artery supplying the anterior spinal artery. There is increasing literature regarding spinal infarction following BAE when arterial supply to the spinal cord was not evident. The existence of unrecognized patient comorbidities may further contribute to procedural risks.

Endovascular Treatment of Multiple Bronchial Artery Aneurysms With Prominent Fistula to Pulmonary Artery in a Patient With Interstitial Lung Disease: A Case Report and Literature Review

Bronchial artery aneurysm (BAA) is a rare entity. Ruptured BAA can cause life-threatening hemorrhage. It is recommended that treatment should be initiated immediately after diagnosis. We present the case of a 56-year-old female with multiple BAAs and interstitial lung disease. Aortic computed tomography angiography demonstrated that the largest aneurysm at the right hilum was fed by right subclavian artery and right bronchial artery. A fistula between the pulmonary trunk and the aneurysm was also revealed. The patient underwent transcatheter embolization. Coils were placed in the feeding vessels instead of the aneurysms to avoid nontarget embolization of the pulmonary arteries through the fistula. The procedure achieved reduction in aneurysmal blood flow. The patient’s cough resolved at 6-month follow-up.

Clearing the Clogged Microcatheter During Particulate Embolization

This chapter describes the steps in management, applications, challenges, and potential complications when a microcatheter becomes clogged during an embolization. If a microcatheter does become occluded during an embolization, it can be a challenge to clear it without removing the catheter completely, thus losing access to the desired location. If a standard 1-cc syringe is placed and manual pressure is applied to clear the catheter, this can generate pressures up to 100 times the arterial blood pressure, thus risking nontarget embolization from the residual embolic material in the microcatheter. This chapter describes the steps involved in safely clearing an occluded microcatheter with the use of a standard balloon insufflator.