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Plugs significantly reduce fluoroscopy time when compared to coils in pelvic congestion syndrome 
Wednesday, 08 Oct 2014 15:58
Alicia Laborda
One-year results from a randomised study comparing fibred platinum coils to vascular plugs for the embolization of pelvic varices in order to treat pelvic congestion syndrome have shown that plugs are as good as coils with regard to safety and efficacy. In addition, plugs also significantly reduce procedure and fluoroscopy time, and radiation dose, the study finds.

The study conducted in Zaragoza in Spain, set out to compare the safety and efficacy of two embolic agents for the treatment of pelvic congestion syndrome: Nester coils (Cook Medical) and Amplatzer vascular plugs (St Jude Medical). The results of the study also showed that device migration and incomplete embolization is more frequent with the coils. 

Alicia Laborda, University of Zaragoza, Group of Research in Minimally Invasive Techniques Research (GITMI), presented the results at CIRSE 2014 (12–17 September, Glasgow, UK).
The researchers enrolled 55 consecutive patients from May 2010 to September 2012, with a mean age of about 44 years (range 29–60) diagnosed with pelvic congestion syndrome who had chronic pelvic pain of more than six months duration, increased venous calibre (>6mm pelvic venous calibre and one of the following: venous ecstasia; venous reflux or presence of communicating veins across the mid-line. These patients were randomised to receive embolization with either coils (n=28) or vascular plugs (n=27) and there were no significant differences between the patient groups at the beginning of the study.
Laborda told delegates: “The median cubital or jugular approach was used interchangeably, using 5F for the coils and 6F for the plugs. Both ovarian and hypogastric veins were targeted. Safety, efficacy, procedure time, fluoroscopy time, and radiation dose were compared.”
All veins were successfully embolized with no differences in both groups. The mean number of coils per case was 17.82±1.39 vs. 4.18±0.48 plugs. There were six cases of repeat embolization procedures due to no improvement in the coil group and two in the plug group. “At one-year follow-up, there were no significant differences in clinical success (complete disappearance or improvement of symptoms 89.3% vs 92.6%) or in subjective improvement self-assessment (by VAS). Two Nester coils migrated and were retrieved without complications. The procedure time, fluoroscopy time and radiation dose were significantly higher in the coil group (all p<0.0001),” Laborda said. The vascular plugs were significantly more expensive than the coils.
SIR-Spheres recommended in new oncology clinical guidelines for treatment of metastatic colorectal cancer 
Tuesday, 30 Sep 2014 11:13 
Newly published European Society for Medical Oncology (ESMO) clinical guidelines for the treatment of metastatic colorectal cancer endorse radioembolisation, specifically with yttrium-90 (Y90) resin microspheres, as a clinically proven technology to “prolong time to liver tumour progression” in patients who have failed to respond to available chemotherapy options.
SIR-Spheres (Sirtex) is the only product used for radioembolisation or selective internal radiation therapy (SIRT) that is recommended in the new ESMO guidelines, a press release from the company says.
The new guidelines, authored on behalf of the ESMO Guidelines Working Group by Eric Van Cutsem (Leuven, Belgium), Andres Cervantes (Valencia, Spain), Bernard Nordlinger (Paris, France) and Dirk Arnold (Freiberg, Germany) were published online in a 4 September 2014 supplement to the Annals of Oncology.
“We are very pleased that the authors of major international clinical guidelines in the treatment of metastatic colorectal cancer have singled out radioembolisation, and particularly our unique product, SIR-Spheres y90 resin microspheres, as an appropriate treatment for patients with colorectal liver metastases that have failed to respond to chemotherapy,” said Nigel Lange, CEO of Sirtex Medical Europe GmbH. “We believe the new ESMO clinical guidelines will have an immediate effect on improving patient access to SIR-Spheres y90 resin microspheres across Europe.”
As clinical evidence for the new ESMO recommendation, the authors cited a multicentre randomised controlled study conducted by Alain Hendlisz (Brussels, Belgium) and colleagues. The study was a “Phase III trial comparing intravenous fluorouracil infusion with yttrium-90 resin microspheres for liver-limited metastatic colorectal cancer refractory to standard chemotherapy.”
In April 2013, Sirtex announced that it had completed recruitment of patients for SIRFLOX, a 500-patient randomised clinical study that compares the use of SIR-Spheres in combination with standard chemotherapy to standard chemotherapy alone in the treatment of patients recently diagnosed with inoperable metastatic colorectal cancer, which is much earlier in the treatment paradigm. Data from SIRFLOX are expected in 2015.
DEFINITIVE LE study results show directional atherectomy is safe and effective in claudication and critical limb ischaemia patients 
Friday, 29 Aug 2014 10:48 
James McKinsey
Directional atherectomy is safe and effective as a frontline therapy for the treatment of peripheral arterial disease, according to a multicentre study published online in the Journal of American College of Cardiology: Cardiovascular Interventions.
Results from the DEFINITIVE LE study using Covidien’s TurboHawk and/or SilverHawk directional atherectomy systems demonstrated 95% limb salvage in patients with critical limb ischaemia and 78% overall patency in claudicant patients at 12 months. The DEFINITIVE LE study is the largest atherectomy study conducted to date with independent, core lab analysis of the clinical outcomes.
“The DEFINITIVE LE study provides confirmatory evidence based on 12-month, independent core lab adjudicated data on the use of directional atherectomy in treating a diverse, real-world group of patients with peripheral arterial disease,” said James F McKinsey, co-global principal investigator and lead author of the study. “The study enrolled 800 patients, making it the largest trial with independent, core lab analysis for atherectomy to date. Results of the study demonstrate high limb salvage, patency rates, and diabetic outcomes. This further confirms the effectiveness and versatility of directional atherectomy in a wide range of vessel sizes and clinical presentations. Atherectomy is an important treatment option as the therapy leaves nothing behind in the body and preserves all future treatment options.”
The prospective, multicentre DEFINITIVE LE study enrolled 800 patients in 47 centres in the USA and Europe and included two patient cohorts: those with claudication and those with critical limb ischaemia. Patients enrolled in the study were treated with the TurboHawk and/or SilverHawk, a catheter-based, minimally invasive treatment to remove plaque and restore blood flow, without leaving anything behind in patients with peripheral arterial disease. For the first time in an atherectomy study, DEFINITIVE LE also included pre-specified subgroup analysis comparing patency rates in diabetic and non-diabetic patients.
“The outcomes for patients with claudication reveal that in the scientific landscape directional atherectomy is not only safe but effective to a similar degree as previous trials in the superficial femoral artery. Diabetic patients, who remain challenging for therapy due to their advanced and multilevel disease, have similar patency rates to non-diabetic patients with claudication when performing directional atherectomy,” said Lawrence Garcia, co-global principal investigator of the study and chief of Interventional Cardiology and Vascular Interventions at St Elizabeth’s Medical Center in Boston. “These findings provide strong clinical support for the versatility of directional atherectomy in treating patients with diabetes, claudication and critical limb ischaemia.”
Among patients with claudication, primary patency was 78% at 12 months. Notably, this rate did not differ between patients with diabetes (77%) and those without diabetes (78%)—the first such results to be shown in a prospective, powered analysis. Specifically for the superficial femoral artery, the patency rates were 83% in lesions under 10cm in the claudicant cohort.
What the trials have taught us about aggressive therapy of deep venous thrombosis 
Thursday, 25 Sep 2014 12:38 
Stephen Kee and Adam Plotnik
Deep venous thrombosis occurs in 3–600,000 patients per year in the USA, and is associated with significant rates of short (pulmonary embolus) and long-term morbidity (post-thrombotic syndrome). Post-thrombotic syndrome has been reported to develop in over 50% of patients within two years following deep venous thrombosis despite standard therapy. The syndrome results from venous obstruction and inflammatory destruction of the valves. Manifestations include chronic limb pain, swelling, heaviness, early fatigue, skin pigmentation and/or venous ulceration. Consequently, there is significant impairment on the patient’s quality of life and the care required places a major economic burden on both the patient and healthcare providers.
Conventional therapy 
Standard treatment of acute deep venous thrombosis is anticoagulation, which prevents pulmonary embolus and the propagation of thrombus, but does not affect the outcome or severity of post-thrombotic syndrome. Historically the only treatment for post-thrombotic syndrome with level one evidence is compression stockings. Thrombolysis, initially published in 1994 by Semba and colleagues in Radiology, has also been used to treat extensive deep venous thrombosis, however, the data supporting its use to prevent post-thrombotic syndrome is limited. Ongoing research and recently published studies are changing the treatment landscape for this devastating disease. This article provides an update of this data.
Data on thrombolysis and acute deep venous thrombosis
A 2014 Cochrane review evaluating randomised controlled trials, with a total of 1103 patients from 17 studies, examined thrombolysis and anticoagulation vs. anticoagulation alone in the setting of acute deep venous thrombosis. They demonstrated significantly less post-thrombotic syndrome in those receiving thrombolysis compared with anticoagulation alone. However, it identified significantly increased bleeding complications (10% vs. 8%). Notably, most of these bleeding complications occurred in early studies (pre-1990), whereas recent adaptations in the standard practice of thrombolysis (lower dose rates and reduced concomitant heparin administration) should mitigate many of these issues.
Only two randomised controlled trials have specifically compared catheter-directed thrombolysis with anticoagulation. Elsharawy and Elzayat (European Journal of Vascular and Endovascular Surgery, 2002) published data from 35 patients, half treated with catheter-directed thrombolysis and anticoagulation, half with anticoagulation alone. They found significantly less reflux and higher patency in the catheter-directed thrombolysis group although numbers were small and short follow-up precluded evaluation of post-thrombotic syndrome. The other more significant randomised controlled trials was CaVent, a Norwegian study that included 209 patients. Half were treated with catheter-directed thrombolysis and anticoagulation, half with standard anticoagulation. Post-thrombotic syndrome was significantly lower in the catheter-directed thrombolysis group. Other observational studies have demonstrated improvement in long-term quality of life following catheter-directed thrombolysis, including Comerota in 2000 (54 patients) and Grewal in 2010 (42 patients). Despite this data, there continues to be widespread reluctance to change the paradigm of treatment for deep venous thrombosis, based mainly on the concerns regarding bleeding risks.
Unresolved questions as to the benefits and risks of catheter-directed thrombolysis may be answered by an ongoing National institute of Health sponsored, multicentre trial, ATTRACT (Acute venous thrombosis: thrombus removal with adjunctive catheter- directed thrombolysis). Patients with an iliofemoral and femoropopliteal deep venous thrombosis are being stratified into catheter-based techniques of thrombolysis vs. anticoagulation alone. The primary endpoint is the development of post-thrombotic syndrome at 24 months, and there will also be a cost-benefit assessment. Their study hypothesis targets a reduction in post-thrombotic syndrome of 33% in the lysis group, with hopefully, a low incidence of bleeding complications. Should this large multicentre randomised controlled trials result in clinical improvement with acceptable risk and an overall cost-benefit, it may shift the playing field in favour of aggressive thrombolytic therapy for deep venous thrombosis.
Why are we not doing more thrombolysis?
The challenge to incorporating catheter-directed thrombolysis into standard practice lies in the fact that post-thrombotic syndrome develops long after the patient’s acute hospital admission for deep venous thrombosis. Many physicians dealing with the acute stage have a low-level of appreciation of the long-term sequelae. Data from trials clearly show a significant reduction in post-thrombotic syndrome with catheter-directed thrombolysis and ATTRACT will hopefully demonstrate further improvement with the added inclusion of pharmacomechanical techniques, and cost-benefit data. Furthermore, with strict adherence to thrombolysis exclusion criteria, meticulous interventional techniques, and close treatment monitoring, the risk of bleeding complications can be minimised. Although current evidence in favour of catheter-directed thrombolysis for deep venous thrombosis may not be robust enough to allow for a shift in clinical practice, that may soon change.
Stephen T Kee is associate professor of Radiology and section chief, Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, USA. Adam Plotnik is a radiologist at the same institution. The authors have reported no disclosures pertaining to the article
Endovascular Management of Upper and Lower Extremity Vascular Trauma
Upper and lower extremity traumas are infrequently seen in the civilian health care system. Their frequency is significantly higher in military facilities during periods of armed conflict. The National Trauma Databank reported that 66% of traumas involve upper and lower extremities, and 18% of these (15% lower and 3.31% upper extremities) are Abbreviated Injury Scale > 3. Vascular injuries involving the extremities are rare, and in fact, only 26% of extremity traumas have vascular lesions. Extremity arterial injuries are a result of penetrating (stab or gunshot wounds) or blunt (traffic accidents, compressions) traumas and iatrogenic injuries. The main mechanisms of vascular lesions include laceration or rupture of the vessel, hematoma development, dissection, pseudoaneurysm or arteriovenous fistula formation, and distal acute ischemia.
In the past 2 decades, diagnostic angiography was used to identify arterial damage, but due to technological advancements, multidetector computed tomography angiography (CTA) has essentially replaced traditional diagnostic angiography. Selective angiography is now reserved for the patients with suspected (previously detected through CTA) vascular injuries and are indicated for endovascular treatment.
A traumatic lesion of the main artery in extremities can be treated with bare-metal stent or stent graft placement, whereas distal branch bleeding can be embolized. Embolization can be performed with coils, vascular plugs, gelfoam pledgets, particles, liquid embolic (N-butyl cyanoacrylate and ethylene vinyl alcohol copolymer), or a combination of these. Endovascular treatment is a minimally invasive option and an alternative to open surgery, which avoids adjacent tissue damage and has potentially lower morbidity and mortality rates than conventional management.
The following cases demonstrate the importance of endovascular treatment for traumatic vascular injuries in the upper and lower extremities.
A 45-year-old man was admitted to the emergency department after being hit by a car. The patient was in shock and hemodynamically unstable. Physical examination revealed a voluminous hematoma in the right thigh. X-rays showed a transverse, displaced fracture of the femur shaft (Figure 1A). The patient’s hemodynamics worsened despite fluid and blood replacement. The patient was sent to the angiography suite for selective embolization and to stabilize his hemodynamic condition.
Procedure Description 
Contralateral femoral arterial access was achieved with a 6-F sheath. Right femoral arteriography showed contrast extravasation from a lateral branch of the superficial femoral artery close to the fracture (Figure 1B). Superselective catheterization of the bleeding vessel was performed with a coaxial system, using a 5-F diagnostic vertebral catheter, a high-flow microcatheter, and a 0.014-inch guidewire. Superselective embolization was performed with sterile gelatin sponge (gelfoam) administration and three Tornado coils (Cook Medical). Final control arteriography confirmed complete exclusion of the bleeding vessel (Figure 1C).
During embolization, it is important to obtain a stable microcatheter position (for example, with a coaxial system) to avoid catheter “kick out” and nontargeted embolization. Correct vessel sizing is necessary to choose the appropriate coil dimension; if the size is too small for the vessel, the coil may migrate distally, and if it is too large, it may push the microcatheter back.
An 85-year-old man presented at the emergency department for hypotension after gluteal trauma. The patient was lucid, and his general condition was rated as average. Physical examination revealed sensitivity and ecchymosis in the right gluteal region. CTA revealed a right gluteal hematoma, with active bleeding from the internal iliac artery and compression of the sciatic nerve (Figure 2A). The patient’s hemodynamics worsened despite fluid and blood replacement. A multidisciplinary team decided to perform angiographic embolization, and the patient was sent to the interventional radiology department.
Procedure Description
Retrograde right common femoral arterial access was achieved with a 6-F sheath. Selective 
catheterization of the right hypogastric artery with a 5-F Simmons 1 catheter demonstrated the bleeding site from the inferior gluteal branch of the right internal iliac artery (Figure 2B). Superselective arteriography was performed with a 0.014- inch guidewire, and a coaxial 
microcatheter was positioned for coil embolization. The bleeding vessel was embolized using two large-volume, detachable Ruby coils (Penumbra, Inc.). Control angiography confirmed the complete embolization of the target vessel (Figure 2C). No ischemic sequelae were observed during the course of hospitalization.
Detachable coils permit precise delivery and deployment, reducing the risk of catheter kick out, and they have the possibility to be retrieved in case of misplacement. The Ruby coils have diameters similar to the 0.035-inch coils, maintaining high-flow microcatheter compatibility. Thanks to their softness and complex shape, it is possible to push them to obtain good packing and permanent occlusion in a short time, which reduces the radiation dose.
A 58-year-old man was admitted for endovascular repair of a right popliteal arteriovenous fistula after surgical repair of right popliteal aneurysm following a gunshot wound. The patient’s right leg was swollen and warm. CTA showed the presence of a right popliteal pseudoaneurysm with an arteriovenous fistula (Figure 3A).
Procedure Description
Retrograde left common femoral arterial access was achieved with a 5-F sheath. A 4-F diagnostic catheter confirmed a voluminous right popliteal pseudoaneurysm with an arteriovenous fistula, which was characterized by direct contrast injection into the popliteal and femoral veins (Figure 3B). An 11-F, 90-cm sheath was positioned from a left femoral approach to the contralateral popliteal artery. A balloon occlusion test was performed (Figure 3C), and then the popliteal aneurysm and fistula were excluded with a 10-mm X 5-cm Hemobahn stent graft (Gore & Associates), which was dilated to 10 mm. Final control arteriography evidenced good popliteal pseudoaneurysm and arteriovenous fistula exclusion (Figure 3D).
We performed a balloon occlusion test by inflating a soft balloon into the popliteal artery. With the balloon in place, we can control the distal flow and decide the most appropriate size of the stent graft to obtain complete exclusion from the arteriovenous fistula. Covered stent release allows the treatment of pseudoaneurysm while preserving distal arterial flow.
A 72-year-old woman presented at the emergency department for a right thigh hematoma after a polytrauma. CTA showed a voluminous right anterolateral thigh hematoma, with diameters of 8 X 5 X 11 cm and evidence of active bleeding (Figure 4A).
Procedure Description
Retrograde contralateral common femoral arterial access was achieved with a 6-F sheath. Right iliac arteriography showed contrast extravasation from a branch of the deep iliac circumflex artery (Figure 4B). Superselective catheterization of the bleeding vessel was performed with a coaxial system, using a 5-F diagnostic vertebral catheter; a 2.8-F, 130-cm microcatheter; and a 0.014-inch guidewire. Superselective embolization was performed with gelatin sterile sponge (gelfoam) and one Axium detachable coil (Covidien). Final control arteriography confirmed good iliac hemostasis (Figure 4C).
Gelfoam is a water-soluble and temporary embolic agent, which is completely absorbed by the body within 2 to 3 weeks. It is used to block arterial flow distally, and if mixed with contrast medium, you will be able to avoid uncontrolled reflux, quickly stopping the active hemorrhage. Distal target embolization is then followed by more proximal occlusion with coils.
An 82-year-old man was admitted to the angiography suite for a large hematoma due to transection of the left brachial artery after an endovascular aneurysm repair. The left arm developed a voluminous bicipital hematoma, with distal pulse deficit and ischemia. The patient’s hemodynamics worsened despite fluid replacement.
Procedure Description
Right common femoral arterial access was performed with an 8-F, 70-cm sheath. Left brachial arteriography showed massive contrast extravasation with unclear evidence of the distal part of the artery (Figure 5A). A coaxial system with a 5-F diagnostic catheter; a 2.8-F, 130-cm microcatheter; and 0.014-inch guidewire was used to regain the distal portion of the artery (Figure 5B). An injection from the 5-F diagnostic catheter confirmed the endoluminal position of the tip of the catheter. A 6- X 50-mm Viabahn covered stent (Gore & Associates) was deployed in the transected arterial segment (Figure 5C). The final control angiogram confirmed complete recanalization of the brachial artery (Figure 5D), and the patient was referred to a surgeon for hematoma evacuation in order to avoid a compartment syndrome.
A stent graft can sometimes be the best option to stop arterial bleeding and replace the native vessel wall to restore flow in the distal tissues.
A 67-year-old woman was admitted from another hospital for a thigh hematoma. CT showed a massive thigh hematoma with active bleeding from the left profunda femoral artery.
Procedure Description
Retrograde contralateral common femoral arterial access was performed with a 6-F sheath. Superselective catheterization of the bleeding vessels from the left profunda femoral artery was performed with a 0.014-inch guidewire and a microcatheter; the contrast injection showed a persistent blush (Figure 6A). Embolization of the bleeding vessels was performed using two 3-mm detachable Ruby coils and 0.25 mL of ethylene vinyl alcohol copolymer (Onyx LES 18, Covidien) (Figure 6B). Control angiography showed complete embolization of the target vessels (Figure 6C).
Onyx LES is a nonadhesive liquid embolic agent that is made of ethylene vinyl alcohol copolymer, dimethyl sulfoxide solvent (DMSO), and tantalum powder. The speed of precipitation and solidification of the polymer depends on the concentration of copolymer dissolved in DMSO, which determines the viscosity of Onyx LES. There are three product formulations on the market: Onyx LES 18 (6% copolymer), Onyx LES 20 (6.5% copolymer), and Onyx LES 34 (8% copolymer), with different viscosities.
Some of the advantages of using Onyx LES include no risk for catheter gluing; slow, controlled, and intermittent injection; transembolization angiography; the ability to conform to the shape of tortuous arteries; and preservation of the option for subsequent surgical resection. However, there are some disadvantages associated with the agent, including the required use of a DMSO-compatible delivery microcatheter, possible embolization of parasitic feeders, pain during injection, the need for skilled operators, and high costs.
The endovascular approach can be a feasible, safe, and effective option to treat the vascular injuries in the upper and lower extremities, allowing for timely and minimally invasive management of peripheral active extravasation. Advances in endovascular materials and embolization agents permit a safe and rapid hemostasis in traumatic injuries.
Lorenzo Paolo Moramarco, MD, is with the Unit of Interventional Radiology, Radiology Department, IRCCS Policlinico San Matteo Foundation in Pavia, Italy. He stated that he has no financial interests related to this article. Dr. Moramarco may be reached at Ova e-mail adresa je zaštićena od spambota. Potrebno je omogućiti JavaScript da je vidite..
Ilaria Fiorina, MD, is a resident, Unit of Interventional Radiology, Radiology Department, IRCCS Policlinico San Matteo Foundation in Pavia, Italy. She stated that she has no financial interests related to this article.
Pietro Quaretti, MD, is with the Unit of Interventional Radiology, Radiology Department, IRCCS Policlinico San Matteo Foundation in Pavia, Italy. He stated that he has no financial interests related to this article.
Endovascular Management of Traumatic Vertebral Artery Dissections
Traumatic vertebral artery (VA) dissection is a relatively uncommon but well-recognized sequelae of cervical trauma, with potentially life-threatening implications. VA dissection can occur as a result of different trauma types that cause excessive cervical rotation, distraction, or flexion-extension injuries. Extracranial components of the VAs have a higher likelihood of dissecting; however, up to 10% of extracranial VA dissections extend intracranially. Intracranial dissections can complicate with subarachnoid hemorrhage and present a poorer outcome.1,2
Early and accurate diagnosis of traumatic VA dissections, before stroke occurs, is essential to starting the most appropriate treatment. The widespread use of CT angiography (CTA) in trauma patient screening has improved our ability to detect VA injuries;3,4 however, an early and precise clinical and radiological diagnosis of VA dissection can still be challenging in trauma patients, mainly due to confounding clinical factors and technical limitations.
To date, there are very few reports on endovascular repair of VA dissections, suggesting that medical therapy is the most commonly indicated therapy and that the endovascular approach is generally either not required or is underused. There are no guidelines for the selection of patients who will benefit most from this procedure. This article focuses on our institutional indications for endovascular endovascular management of traumatic VA dissections and the considerations for choosing different endovascular strategies.
Approaches to the management of traumatic VA dissection have developed based on clinical experience with internal carotid artery (ICA) dissections. In cases of spontaneous ICA dissection, anticoagulant treatment is usually recommended to prevent thromboembolic stroke originating from the injured vessel wall5,6 however, anticoagulation is not innocuous and may be contraindicated, especially in patients with multiple traumatic injuries. 
Furthermore, anticoagulation and antiplatelet therapy do not improve compromised perfusion, which may develop secondary to arterial narrowing and lead to hemodynamic insufficiency, or cases complicated with major acute life-threatening injury or embolic events.7,8 Thus, in selected patients with traumatic supra-aortic dissections, endovascular approaches are considered a valuable management option. Stenting allows immediate VA revascularization, reducing the incidence of embolic and hemodynamic stroke without the need for full anticoagulation, and may be combined with other endovascular procedures (eg, thrombectomy, angioplasty, deliberate arterial occlusion, infusion of different agents) based on a specific patient’s requirements.
Patients admitted to the emergency department for head, neck, or multiple traumatic injuries are primarily evaluated with noncontrast head and neck CT, based on our institutional protocols and in accordance with accepted screening guidelines. CTA is routinely performed in patients with suspected neurovascular injury, including all patients with cervical spine injuries. Catheter-based contrast angiography of the cervical and cerebral vessels is performed in cases of penetrating neck injuries or in situations in which neurovascular injury is suspected or proven on CTA; in cases of acute focal neurological signs that are in apparent contradiction to presentation on post-trauma CT, including cases of normal CTA; and in patients presenting with lower cranial nerve neuropathy or Horner’s syndrome. When there is no contraindication, anticoagulation is administered to all patients with traumatic ICA or VA dissection.
The clinical and radiographic criteria used in recently published studies7,8 to determine whether VA dissection patients were candidates for endovascular management include:
(1) Major contraindication for anticoagulation, usually due to the presence of traumatic intracranial hemorrhagic lesions, a large brain infarction, multisystemic hemorrhagic injuries, or the need for surgical or invasive procedures.
(2) Impending risk of stroke based on analysis of dissection severity, type, and location, as well as evaluation of both vertebral arteries and assessment of the presence and collateral blood flow via the posterior communicating arteries (PComAs). At the high end of the risk continuum would be a patient presenting with a hemodynamically significant dissection, string sign, or acute occlusion in a dominant or sole VA, without PComAs, especially in the presence of fluctuating neurological status. Patients at high risk of stroke should be considered for urgent endovascular reconstruction.
(3) Clinical failure of anticoagulation. Patients who continue to suffer from repetitive transient ischemic attack (TIA), neurological instability, and/or neurological deterioration despite anticoagulation are regarded as nonresponders who are at high risk for stroke.
(4) Ischemic stroke secondary to VA dissection with indication for emergent intracranial revascularization procedure. Patients who are candidates for emergent intracranial revascularization procedures are considered for combined intra- and extracranial revascularization (Figure 1).
Routine trauma evaluations, full evaluation to rule out or identify hemorrhagic injuries, and assessment of the cervical spine are mandatory. VA dissections occur most frequently at the V2 segment but may also occur in other locations or extend to more than one segment. They may occur in a dominant or hypoplastic artery, in patients with or without a complete circle of Willis, and in patients with or without rich collaterals. Evaluation of the vascular status and potential collateral supply (and thus the vascular reserve) is of paramount importance to guide therapeutic options and define procedural risks.
Due to the many confounding variables that affect the neurological status of patients with traumatic injuries, stroke evaluation with traditional scales is usually inaccurate. A posterior circulation ischemic event may present with a wide variety of syndromes. Neurological dysfunction may include hemi- or quadriparesis, deficits in cranial nerves III to XII, respiratory difficulty, altered sensorium, vertigo, and/or ataxia. Multiple cranial nerve signs indicate involvement of more than one brainstem level. Patients may present with only hemiparesis, but this may progress rapidly to quadriparesis or a locked-in syndrome.
Clinical suspicion associated with a CTA diagnosis of VA dissection and the detection of a corresponding ischemic lesion on advanced brain imaging (diffusion MR studies) have been the diagnostic basis for therapy. Therapeutic strategies include anticoagulation, revascularization techniques (stent-assisted arterial reconstruction), and endovascular permanent arterial occlusion. When endovascular approaches are indicated, we prefer to use revascularization techniques, especially when dealing with dominant arteries or patients with limited collateral status. Permanent arterial occlusion was considered only in the case of severely injured hypoplastic vessels, where injuries did not involve the PICA origin, and in patients with an absolute contraindication for antiaggregation therapy.
Every patient with a suspected diagnosis of VA dissection based on CTA findings is taken to the endovascular suite for diagnostic cervical and cerebral angiography and eventual endovascular treatment when warranted. Local anesthesia, conscious sedation, or general anesthesia may be used depending on the patient’s clinical status and level of cooperation. A 4-F introducer sheath is placed in the right femoral artery, and a selective bilateral subclavian- VA artery, common carotid artery, ICA, and external carotid artery angiographic study—including extracranial and intracranial circulation—is performed. Every lesion is analyzed in multiple angiographic positions and graded based on the aforementioned criteria. Potential working positions are identified in the preliminary diagnostic study. If a VA endovascular procedure is planned, the 4-F femoral introducer sheath is exchanged for a 6-F introducer sheath. Following our protocol, diagnostic angiography is performed under a low dose of heparin (bolus of 1,000 units IV). In cases in which the need for endovascular 
revascularization is confirmed, the patient receives an additional heparin bolus (70 units/kg) to achieve an intraprocedural activated clotting time of 250 to 270 seconds before the therapeutic procedure commences. Moderate levels of anticoagulation are maintained for the duration of the procedure, and then heparin is discontinued.
A 6-F guiding catheter is placed at the subclavian artery in cases of proximal VA dissection or at the proximal VA when the VA dissection is more distal, and selective angiography is performed. The dissected segment is characterized. Normal arterial diameters, lesion extension, severity of stenosis, and associated lesions are measured with the guiding catheter used as a reference diameter, and an appropriate stent for implantation is selected if stenting was indicated. Severity of stenosis is calculated using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method.9 Unsubtracted images are often very useful at this stage to provide bone references for more precise stent deployment.
The narrowed arterial segment is crossed under road mapping with a 2.3-F microcatheter over a 0.014-inch, 300-cm-long exchange microguidewire. When the microcatheter has fully crossed the dissected segment, adequate positioning of the microcatheter in the true lumen is confirmed with a 1-mL contrast injection. The microcatheter is then exchanged for the stent delivery catheter, and one or more stents are deployed to fully cover the VA dissection.
Only premounted balloon-expandable stents (Promus coronary stent, Boston Scientific; Codman system, Codman Neuro) are used for dissections localized to the V1 segment, while either self-expanding microstents (Wingspan, Stryker Neurovascular; Leo stent, Balt Therapeutics; Solitaire AB, Covidien) or balloon-expandable stents are used in the V2 and V3 segments, based on the neurointerventionist’s preference. The aim of stenting is to cover the injured arterial segment and improve the arterial diameter. Post-stenting residual arterial stenosis of < 30% is considered a good result. Immediately after stenting, heparin is discontinued, and patients receive a loading dose of 300 mg aspirin and 300 mg clopidogrel orally or per nasogastric tube. Oral clopidogrel (75 mg) and aspirin (100 mg) are prescribed once a day for 4 to 6 weeks; aspirin is continued indefinitely. Patients who undergo implantation of regular neurostents, those considered at high risk for hemorrhage, and those who must undergo a surgical procedure receive aspirin with or without a reduced course of clopidogrel.
Low-porosity stents or flow diverters, such as the Pipeline embolization device (PED, Covidien), are used in cases with high embolic potential or in cases with associated pseudoaneurysm. Due to the increased risk of stent thrombosis, PED implantation is always preceded by administration of antiplatelet agents, and the antiplatelet effect is evaluated. These patients are premedicated with a loading dose of 300 to 600 mg of clopidogrel (based on the duration of the premedication; the shorter the premedication period, the higher the loading dose), followed by 75 mg daily. In addition, all patients receive 300 mg of aspirin daily. Thrombocyte inhibition levels are confirmed with the VerifyNow P2Y12 assay (Accriva Diagnostics, representing ITC and Accumetrics) and a standard thrombocyte aggregation test. Patients are treated only if the thrombocyte inhibition level is > 30%; if the response is lower and without resistance, additional loading doses or increased daily doses (eg, 150 mg daily) are administered. If clopidogrel resistance is detected, clopidogrel is discontinued, and ticlopidine is administered at a dose of 600 mg twice daily.
Antiplatelet medications are transiently discontinued when indicated for mandatory surgical or other invasive procedures. Neurological and neuroradiological examinations are performed at discharge and at 1-, 3-, and 12-month follow-up. Stent patency is assessed by CT angiography or formal angiography at 3 and 12 months.
We present our indications for angiographic evaluation of trauma patients with suspected supra-aortic trunk traumatic injuries, and criteria for identifying patients who are candidates for endovascular management of traumatic VA dissections based on our experience and the scarce reports available in the literature. In addition, we present the preprocedural work-up and steps of the endovascular procedure in our center.
Anticoagulation is the most commonly used therapy for VA dissection. It is generally accepted that anticoagulation is effective in preventing stroke and presents an acceptable safety profile in patients without increased risk of hemorrhage. However, the indications for anticoagulation in a multitrauma patient can be complex, and treatment should never be taken without balancing risks. Existing evidence on the optimal treatment of traumatic VA dissections is limited and can only guide the general practice to identify patients who are candidates for anticoagulation with acceptable risks for hemorrhagic complications, or who could be managed with alternative antithrombotic prophylaxis if formal anticoagulation is contraindicated. Although it is difficult to prove, antiplatelets alone are considered less effective but are thought to be generally safer in terms of hemorrhagic complications, in comparison with anticoagulation. The logic behind endovascular revascularization is to reduce the risk of ischemic stroke while gaining the more acceptable risk profile for hemorrhage and the contraindications associated with antiplatelets.
From 2004 to 2014, out of a series of 46 patients with traumatic VA dissection, 18 patients presenting with 24 traumatic VA dissections met inclusion criteria for endovascular therapy. A total of 19 dissections were managed with VA stenting as the primary treatment modality, including stent-assisted reconstruction or diverter implantation. Three dissections were treated with deliberate arterial occlusion using detachable coils, two patients required emergent intracranial revascularization procedures, and one required endovascular embolization of an associated vertebral arteriovenous fistula. We have found this management approach to be safe and not associated with an increased rate of complications. In general, our experience coincides with most reports that stenting extracranial dissections is safe, and associated with a stable or improved neurological outcome.
In 2011, Pham et al10 published a thorough review of the recent literature on endovascular management of carotid and VA dissections. They assessed eight reports describing the management of 10 patients and 12 dissected vessels. Etiology of the dissections was traumatic (60%, 6/10), spontaneous (20%, 2/10), and iatrogenic (20%, 2/10). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2–12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3–55 months).
It is our impression that stenting supra-aortic dissections has become a routine procedure in most neurocatheterization laboratories, and we were surprised by the small number of patients that this complete review gathered, considering the fact that advanced vertebral stenting has been performed for more than a decade.
In the coming years, it will be crucial for us to define appropriate therapy for traumatic vertebral artery dissections: which patients should receive anticoagulation, who should receive antiplatelet therapy and for how long, who should be stented, and which stents should be used. Therapy will have to effectively prevent stroke with minimal additional morbidity in patients who may be suffering from traumatic injuries, and it will have to allow immediate additional surgical or invasive procedures with minimal restraints when required. Advances in endovascular therapies have led us to consider the endovascular alternative for patients who meet specific criteria of increased risk for stroke. This approach has allowed controlled and predictable restoration of the distorted, damaged anatomy in 
patients with VA dissection, reducing the early risk of stroke and allowing us to continue with surgical plans with acceptable limitations. We have also been able to eliminate long-term anticoagulation, with its limitations and undesired risk of hemorrhagic complications. 
Based on our experience, we are convinced that stenting is a continuously evolving field with a definite place in the management of supra-aortic dissections. Prospective randomized trials compared with medical management are needed to further elucidate the role of endovascular 
José E. Cohen, MD, is Professor of Neurosurgery and Chief, Division of Endovascular Neurosurgery, Hadassah–Hebrew University Medical Center, Jerusalem, Israel. He stated 
that he has no financial interests related to this article. Dr. Cohen may be reached at +972-2-
677-7091; Ova e-mail adresa je zaštićena od spambota. Potrebno je omogućiti JavaScript da je vidite..
Shifra Fraifeld, MBA, is a senior medical writer and research associate, Hadassah–Hebrew 
University Medical Center, Jerusalem, Israel. She stated that she has no financial interests 
related to this article.
Eyal Itshayek, MD, is a senior neurosurgeon, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. He has disclosed that he is the recipient of research support from MFast, an Israeli distributor of a wide variety of medical devices.
Endovascular Management of Abdominal Solid Organ Trauma
Endovascular management of blunt trauma to the abdominal solid organs is the standard of care for hemodynamically stable patients without signs of peritonitis.1-3 This strategy is associated with less hospital cost, earlier discharge, fewer intra-abdominal complications, and a reduced transfusion rate, without increased morbidity.4
The high success rate of this approach is only possible with the use of angiography and embolization (A&E) as adjunctive therapy, when appropriate.5,6 Awareness of the subgroup of patients who can benefit from endovascular management and familiarity with the technique is crucial to avoid additional risk and cost by not adding unnecessary procedures.
Although any solid intra-abdominal organ can be injured after blunt trauma, including the pancreas and adrenal glands, this discussion will be limited to the spleen, liver, and kidneys, as they represent the most relevant sources of bleeding that can lead to death.
Splenic Trauma
According to the latest Eastern Association for the Surgery of Trauma practice management guidelines for blunt splenic injury, angiography should be considered for patients with an American Association for the Surgery of Trauma (AAST) grade > III, presence of contrast blush on abdominal CT, moderate hemoperitoneum, or clinical evidence of ongoing bleeding.1
Hepatic Trauma
According to the latest Eastern Association for the Surgery of Trauma practice management guideline for blunt hepatic injury, angiography should be considered in patients with an AAST grade ≥ III, presence of contrast blush on CT, and evidence of hepatic venous injury.2
A&E is also considered first-line therapy for patients who are transient responders to resuscitation,which represents ongoing bleeding.
Renal Trauma 
Similar to the other organs, A&E is indicated in stable patients if CT scan shows contrast 
blush, pseudoaneurysm, or arteriovenous fistula.In addition, according to the 2014 American Urology Association guidelines, A&E should also be considered in hemodynamically unstable patients.3
The universal and most reliable CT finding of active bleeding is contrast material extravasation and should always prompt A&E. If found, so-called contained vascular injuries should also lead to A&E. These findings are well described for splenic lesions,9,10 but can also be used in the setting of hepatic and renal traumatic injury.
Contrast extravasation is characterized by linear or irregular areas of contrast material enhancement with similar intra-arterial attenuation coefficient, which tends to expand on delayed phases (Figure 1). Contained vascular injuries or “nonbleeding” vascular injuries include pseudoaneurysm and arteriovenous fistula. Different from contrast material extravasation, those lesions tend to appear as well-circumscribed areas of high attenuation coefficient, usually surrounded by a hypodense region, with the tendency of turning isodense to the surrounding parenchyma on delayed phases (Figure 2).
Pseudoaneurysms are formed by an arterial wall injury, allowing blood extravasation that is partially contained by other surrounding structures. Therefore, these lesions are unstable; up to two-thirds of them may ultimately rupture, leading to unsuccessful endovascular management if not correctly treated.9
As shown by Boscak and colleagues,11 dual-phase CT provides better overall performance to differentiate those types of lesions when compared to single-phase CT, although this may not change clinical management because patients with either contrast material extravasation or contained vascular injuries should be referred to angiography.
In the setting of hepatic trauma, another finding that has been correlated with arterial injury is involvement of a major hepatic vein.12 In this study, 88% of the cases with active hepatic arterial bleeding also had hepatic vein involvement, whereas in patients without active hepatic bleeding, only 34% had injury extending to a major hepatic vein. Therefore, the authors suggested that patients with grade IV to V lesions associated with hepatic vein involvement should be referred for angiography, even without evidence of contrast extravasation or pseudoaneurysm.
As previously mentioned, additional CT findings that also influence the indication for A&E are the AAST grade system and the severity of hemoperitoneum. AAST grade classifications are available to describe splenic, hepatic, and renal traumatic injuries. The severity of hemoperitoneum can be determined by dividing the peritoneal cavity in five compartments (perisplenic space, Morison’s pouch, left and right paracolic gutters, and pelvis): small is defined as blood in only one or two spaces, moderate is blood in three or four spaces, and large is blood in all five spaces.10
Digital subtraction angiography should be tailored to the CT findings in order to minimize procedure time, radiation exposure, and volume of iodine contrast material. An initial anteroposterior view should be acquired, with the acquisition time long enough to visualize the venous return, including opacification of the portal system, in case of hepatic or splenic injuries. Selective catheterization with oblique views is extremely helpful, as it increases the sensibility for detection of vascular abnormalities. Similar to CT, angiographic findings include contrast material extravasation, pseudoaneurysm, and arteriovenous fistula (Figure 3). In addition, angiography has higher sensitivity for detecting arteriobiliary and arteriocalyceal fistulas. Abrupt arterial truncation can also be observed and could represent either vessel dissection or transection. The latter could lead to intermittent bleeding in cases of increasing pressure head in the arterial system, if the patient’s hemodynamic status improves. Therefore, embolization should be considered in cases of traumatic arterial occlusion.13
Splenic Embolization
Different techniques have been used to treat splenic trauma, including proximal, distal, and combined splenic embolization. In terms of effectiveness in achieving hemostasis, the difference between these techniques has not been shown.14,15 Overall, distal embolization has been used when focal parenchymal contrast material extravasation or contained vascular lesions are found. Due to the amount of splenic collateral circulation, proximal embolization would not be effective in treating a distal lesion due to the potential risk of back bleeding.
Proximal embolization is used when no focal lesions are present and in the setting of severe traumatic injury (grade IV/V). Proximal embolization has also been described when multiple bleeding sites are present, making selective embolization more challenging and time consuming. In theory, that would allow clot formation by decreasing parenchymal arterial flow to those multiple injured sites.14
Distal embolization is associated with a higher incidence of complications, including abscess and pseudocyst formation.16 This is due to parenchymal infarction, as the result of terminal branches occlusion. Even with the increased risk for infarction, distal embolization is always recommended when a focal parenchymal lesion is identified.
On the other hand, proximal embolization can lead to ischemic pancreatitis, as the pancreas is supplied by proximal branches of the splenic artery (dorsal pancreatic and pancreatic magna arteries). Therefore, when considering proximal embolization, those vessels need to be identified, and the embolic device should be placed distal to their origin.
For distal embolization, a microcatheter is used coaxially for superselective catheterization of the target vessel, and embolization can be performed with coils, gelatin sponge, or glue. Among the variety of coils available, pushable fiber coils are the most often used because they are less expensive, they are faster to deploy, and the risk of coil migration is not substantial. Usually, choosing a coil 1 mm bigger than the vessel is sufficient to achieve adequate sealing and to avoid distal migration. Gelatin sponge can be used in the form of a slurry. For this, the bar of the embolic agent is cut in small pieces and mixed with contrast material through a three-way stopcock connected to two syringes.
Cyanoacrylate, known as glue, is an adhesive liquid embolic agent that can also be used for distal embolization. The agent solidifies when it comes in contact with an ionic solution such as blood, and the time for solidification depends on the applied dilution. The agent should be mixed with lipiodol, which is a nonionic material that provides radiopacity for the solution. Usually, a 50/50 mixture is utilized; if faster solidification is desired, a higher proportion of glue should be used. To avoid solidification within the delivery catheter, the system should be filled with a solution of 5% dextrose. Finally, the mixture is injected for a few seconds; removal of the catheter should not be delayed in order to avoid catheter entrapment (Figure 4). The advantages of glue are its low cost, availability, and effective distal embolization, whereas the biggest disadvantage is the potential risk of having the catheter stuck within the vessel.
For proximal embolization of the splenic artery, coils and vascular plugs are the agents of choice. When using coils, 1 to 2 mm upsizing is recommended. In contrast to distal embolization, detachable coils play a more important role, as the main splenic artery is a calibrous high-flow vessel. In this situation, distal migration is more detrimental because large parenchymal areas can be infarcted.
Vascular plugs require significant upsizing, usually 40% bigger than the vessel. Depending on the size of the chosen plug, the delivery system can be as small as a 4-F diagnostic catheter. However, larger devices will require larger delivery systems. This can add some difficulty to the procedure, as the splenic artery is a tortuous vessel, and proper system positioning and stabilization can be challenging.
A meta-analysis published by Schnüriger and colleagues14 showed wide variation of failure to achieve homeostasis from 0% to 33.3%, with a pooled overall failure of 10.2%. A more recent 
publication including 50 patients demonstrated similar results, with an 8% failure rate, but without a statistically significant difference among the techniques (proximal vs distal).15
According to the same meta-analysis, the most common complications were infarction and infection, with an incidence of 0% to 19.8% and 0% to 1.9%, respectively. Frandon and colleagues reported a 4% infarction and 16% infection rate.15 Schnüriger also showed that minor complications were more associated with distal embolization, which was also demonstrated by Ekeh and colleagues.16
Finally, one additional issue has been raised in regard to the patient’s immune system status after splenic embolization. Initially, there was a concern that embolization in the setting of blunt splenic trauma would affect the immune system in a similar fashion to splenectomy. However, studies have shown no difference in the immunologic profile of patients who underwent splenic embolization compared to control groups.17-19
Hepatic Embolization
Different from embolization of the spleen, hepatic embolization is mostly performed distally after selective catheterization of the main branches of the proper hepatic artery or even superselectively with access into segmental branches. Therefore, coils, glue, and gelatin sponge are the embolic agents of choice, and vascular plugs play a minimal role (Figure 5).
Although the liver parenchyma has a dual blood supply from the portal vein and hepatic artery, ischemic complications can occur after hepatic artery embolization. A recent series demonstrated that 16% of the patients who underwent embolization required debridement of necrotic liver parenchyma.20 This could be explained by associated traumatic focal injury to the portal venous system, leading to complete lack of blood supply. Gallbladder ischemia was also an important complication, occurring in 16% of the patients, all of them requiring cholecystectomy. The best way to avoid these complications is by pursuing superselective embolization, limiting the devascularized area. To avoid gallbladder ischemia, the takeoff of the cystic artery should be identified and the catheter positioned beyond that level. In > 63% of patients, the cystic artery will arise from the right hepatic artery and, less commonly, from the proper hepatic artery or left hepatic artery.21
Renal Embolization
Among all of the organs described so far, the kidney is the least forgiving in terms of tissue infarct due to the irreversibility of nephron loss and potential long-term renal dysfunction. In addition to the ischemic injury caused by embolization, those patients are at risk for contrast-induced nephropathy and acute tubular necrosis due to hypovolemic shock. Fortunately, coaxial use of a microcatheter allows superselective catheterization of the injured vessel, minimizing normal parenchymal compromise.
Similar to the liver and spleen, the use of different types of embolic agents has been described, including coils, gelatin sponge, glue, and polyvinyl particles.22 Among them, coils offer better delivery control and are therefore the preferred agent to avoid nontarget embolization. Pushable coils are well suited for this use, but for more complex lesions, detachable coils can be used to increase the safety of the procedure, despite their higher cost (Figure 6).
Technical and clinical success rates have been described as high as 90% and 79%, respectively.23 Regarding tissue compromise, Sofocleous and colleagues calculated a gross 
estimated parenchymal loss in < 30% of patients based on a comparison between pre- and postembolization arteriograms.22 In this series, no patient with an initial normal creatinine level developed renal failure after the procedure. Other adverse events described in the literature are renal artery dissection (7.5%), pyrexia (9%), pain (5%), and abscess formation (1%).23
Endovascular management of traumatic injuries of solid intra-abdominal organs is part of the practice of every trauma center. Familiarity with the indications and available embolic agents is crucial to improve outcomes while avoiding additional unnecessary risk and cost to the patient’s care.
Ricardo Yamada, MD, is with the Division of Vascular and Interventional Radiology, Medical University of South Carolina in Charleston, South Carolina. He has stated that he has no financial interests to disclose. Dr. Yamada may be reached at (843) 876-5556; Ova e-mail adresa je zaštićena od spambota. Potrebno je omogućiti JavaScript da je vidite..
Marcelo Guimaraes, MD, FSIR, is with the Division of Vascular and Interventional Radiology, Medical University of South Carolina in Charleston, South Carolina. He has stated that he is a consultant with Terumo Interventional Systems and a consultant and patent holder with Cook Medical.
Claudio Schönholz, MD, is with the Division of Vascular and Interventional Radiology, Medical University of South Carolina in Charleston, South Carolina. He has stated that he has no financial interests to disclose.