EMBOLIZATION PROCEDURES

how to detach ruby coils

might seem basic but a Vasc Surgeon once asked me

Make sure to have detacher placed on table
have microcatheter in vessel of targetendoleak embolization
remove microwire from microcatheter
keep in mind coil placement could push microcatheter out so have a solid position of catheter
take coil from coil pack
the front end will have a small french size sheath that goes in the microcatheter
the back end is a wire with markings on it
find back end of sheath and start pushing the wire forward through the sheath
the wire should go smoothly with some points of resistance as it travels into the microcatheter
once reach end of wire, remove sheath and place on table. might need to re-use
advance wire to end of microcath and watch under fluoro
if using Ruby, should see coil forming at the catheter level
of note use standard coil initially as scaffold and pack multiple soft coils after
achieve desired coil placement and configuration. can back coil out and re insert to form different configurations. can use coil as wire to move catheter position slightly as well
once have desired coil position and configuration, detach coil
check detacher function by pulling back clicker and should hear solid click
place back end of wire into detacher and click back
pull free end of coil back under fluoro and check to see if coil remains
if detacher not working correctly, can detach coil manually (off label) by bending back end of wire back and forth till it breaks, finding a small filament and breaking the filament
pull out wire. take wire and sheath and fold up-> tarsh it
after coil placement, can wait a few minutes to thrombose vessel and then do contrast injection under fluoro or hand run

JF method Endoleak Embolization

pt. has AAA s/p endovascular exclusion device
different types of endoleak
type 2 is common
meaning excluded sac is filling by lumbar artery or IMA
this can be seen as enlargement of the excluded sac
or by actually visualizing contrast opacification of the sac on CTA or duplex US

procedure:
use CT and fluoro guidance
direct sac puncture technique

using greb set (15 cm 21 g trocar needle, 5F dilator-sheath, microwire (018 wire)
using CT guidance, access the excluded sac. Go in place along psoas, to the left or right of the midline (pt will be prone)

once successfully accessed with 5F sheath transfer to fluoro

Under fluoro will be using a 4 or 5F glidecath angled tip to do procedure. Can use Bentson or Glidewire
Goal of procedure is to access areas of the excluded sac and try to demonstrate flow, either through injection under fluoro or hand DSA run
Once have catheter within region of flow, can infuse embolic agent.
Of note, can use 130 cm progreat microcath-microwire to interrogate different areas of the sac as well
if can cannulate near the actual feeding artery and identify, this is ideal to produce definitive embolization
however, if cannot access feeding vessel directly, secondary goal is to increase pressure within sac using multiple embolic agents

embolic agents:
gelfoam: create gelfoam slurry using contrast and infuse through catheter to reduce flow
coils: can use Ruby detachable coils or POD coils. Can use large diameter and length to create embolic "scaffold"
Onyx: good agent to end the case with. In order to use, have microcatheter tip in desired location. infuse DMSO into catheter (this prevents the agent from sticking to the catheter). Then infuse onyx as 1 cc injections. Do intermittent fluoro in order to check onyx infusion and desired placement. Do not want to over-infuse and produce nontarget embolization outside of sac

once desired result is achieved, can do some angled fluoro saves to capture extent of embolization

once completed, remove all catheters and wires and hold pressure at site till hemostasis.

Renal arteriogram +/- embolization

to evaluate possible renal artery bleeding, pseudoaneurysm, AVF, or other reno-vascular lesion

renal artery 1

renal artery 2

possible scenarios:

post partial nephrectomy with hematuria

hematuria with pain

lesion on CTA

post nephrostomy with hematuria in bag

procedure:

obtain RCFA access using micropuncture and place 5F vascular sheath with sidearm

start with 4F cobra catheter, bentson wire (have glidewire on table)

Go to renal artery, L1-L2 level, inf. to SMA

try to cannulate ostium

perform hand infusion to confirm

hook up for angiographic run, 4 for 8

consider prior to performing run augmenting c arm for better picture, ie adjust cranio caudad, mag or other

analyze images for abnormality

to perform further intervention can use 130 cm progreat microcath-microwire

keep in mind renal artery is end organ and can lose renal function

subsection: how to exclude PSA using onyx

neurovascular techniques

unsure of exact catheters and sheaths

using a 6F intermediate catheter in the AA

can use two microcath through above cath

can perform baloon assisted onyx embolization to exclude PSA without losing renal function (as opposed to coils)

goal is to place adequate sized baloon across lesion ostium

then cannulate lesion

then inflate baloon

then infuse onyx, keeping in mind to infuse to endpoint without nontarget embolization

then deflate baloon

perform post angiographic run

Re. Penumbra Ruby Detachable coils
sometimes if you want to retrive a coil into the sheath, the coil can unbekownst to you, deploy into the catheter and possibly nontarget embolize

saw this once, planned embo of Inf Epi Art and coil prolapsed and fell into Profunda femoris (could have trashed foot if went in SFA)

use Amplatz Gooseneck snare device to retrieve, in that case was successful

need to make sure snare size is approp

To get up and over iliac bifuraction:

use reverse curve cath and Bentson vs. Glide

Rev Curve: SosS2, Cobra/ GlideCobra, simmons, contra

Arterial Anatomy:

Check barbeau, access L radial, place 4-5 Glidesheath slender Terumo

advance J tip Glide preloaded on 125 cm Impress or other angled catheter

Use catheter to snag the Internal iliacs, can start on right

instead of doing runs, do fluoro saves uses small puffs of contrast

find uterine artery

can now advance micro, prefer 2.9F cantata cook micro and double angle GT Glide 018

use roadmap or fluoro save to access uterine artery

get microcath past cervicovaginal branches, usually on horizontal portion of artery

do a pre fluro save

embolize with particles, prefer 500-700 embospheres, x 1-2 vials, per side

do post fluoro save, remmber to pull bac micro so can show reflux into internal iliac

do the contra side

pull all out and close L radial with TR band

start pt on PCA in the room

other post orders include zofran IV, tordol IV, phenergan suppository

d/c meds are oxy, docusate, phenergan, and zofran i beleive

Bronchial Artery Embolization (BAE)

review preprocedure CT

find landmarks to investiagte with catehter

get 5F sheath R groin

use 5F mikaelson cath over 035 bentson

investigate with mik and contrast

can first do flush aortogram with flush pigtail

once get access to vessel, use micro, such as renegade and transcend

embolize with 3-500 micrno particles, embospheres

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Femoral UFE SD

R groin access 5 F sheath

use omni flush / contra flush to get over bif, use bentson

exch for RUC catheter

you sorta form this at the apex fo the bif

sorta hard for me to do

when you torque a catheter, you dont just twist it, you advance and twist (per JM)

if you just twist and twist you can tie that up in a knot (BAD*** been there done that)

you sorta wiggle it into the Internal Iiliac

from there do some obliquing and find the uterine, usu has tons of flow

get the micro in there, spin the wire and it finds the highest flow (IB techn)

get micro out into horizontal, want to be past the cervicovaginal branches

use 5-700 micron beads, look for stasis

SD infusion method: slow steady stream, hold the stopcok infuser sidways to get even mix of beads and saline/contrast (gangsta style gun hold method)

if the ute is huge gonna take lots of cans (4-5 vials can happen)

to switch over to other II, push catheter out into aorta and then wiggle it back into ipsilateral II

takes a bit of maneuvering

DO NOT TWIST AND TIWST- you will tie it in a knot and be f'd

always advance and retract while torquing

close with vascade

nuthin else to say

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embolization technique:

Flow redistribution

can be used to redistribute flow to a desired distribution and away from an undesirable place

for example, want to direct flow to a hepatic tumor

embolize the portion that is distal- can use gelfoam

in other areas, have seen coils used - for example in DFA dist - CG
make the angiogram look how you want it and then do your embo- including chembo

nice trick - seen in it used in chemoembolization

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UFE- IB method

prefer goinr access, RCFA

5F sheath

RUC cath - purple UAC catheter

no wire to select Int Iliac

once inside II, puff forward to find uterine

TRICK: when using microwire microcatheter

use just the microwire- GT glidewire preferred

if you advance the GT glide first thru the base catheter (UAC)

99% of the time pER IB, it will find the right vessel, due to flow dynamics and preference for flow

the wire will be like the blood and go to the sump of arterial flow - the fibroids

can then track microcatheter over the wire but be careful

theorteical risk of the microwire embolizing somewhere as a intravasc foreign body, unlikely though

do contra side

do aortogram with catheter just under renals to exclude ovarian arterial supply

close with vascade

of note, use "physiologic" doses of nitroglycerin IA: meaning 800 micrograms each side, the HR drops

"what you know about vectors Doctor?"

"Doctor? Doctor?"

FORMING A SIM1 GLIDECATH WITH TEVDEK SUTURE

DK METHOD
take a tevdek sharp end to a needle driver protected

advance just the amtount of the first curve of a sim1 into the cahter

advnce the catherer over a wire

pull the wire till its tip to tip with the cath

now pull the suture to form the sim

once its formed, pull the wire back

then pull the suture out

that should be it

GDA embo:
track a micro out to the R Gastro epiploic

coil that shit back

make sure you dont prolapse into the common hepatic

3-6 mm coils, can use detachable terumo Azurs Cx or whatev

GIB:

remember endoscopy is really a first choice modality. figure out why they can't go with endoscopy first

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BAE (bronchial artery embo)

situation:

fungal disaese

things to think about

is it truly massive- definitions vary. 200 cc is a reasonable cutoff

HD stable?
hgb stable?
active type and screen- blood products avail

airway secure? should we call anesthesia?

do we know what side? does the pt know what side?

is there a CTA? can we get one? What is the GFR?

Is there a previous bronch?

can a bronch be performed?

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Ovarian Vein Embolization

for pelvic venous congestion

had pt on 8/1

had pelvic pain

had MRV with enlarged L parautereine veins

did with JR

R jug entry

use JB1 cath with glide and bentson

cath L renal- L gonadal

once down and do venogram, advance 5F sheath

examine images and decide how to sclero and embo the veins

to inject scerolsant- infuse contrast to decide volume, something like 1-2 cc

then clear cath of contrast

infuse the scerlosant- 3% sotradecol foam (air sotra, no lipiodol per JR)

finuse about 1 cc of sclersant

then chase with contrast

as soon as see contrast, stop

then coil the vein

oversizing is preferred, for ex for 5 mm vessel, use 8 mm coil

place a few coils, then repeat the venogram to see where to go next

keep chasing some veins until you feel you have embo'd most

then place plug device

again oversize, 5 mm - use 8 mm plug

can also investigate R ovarian vein

Can also investigate internal iliac venous supply- controversial whether to treat upfront

follow up in 1 mth- check for symptoms

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Ovarian vein embo

did one around11/25/2017

intresting case with bleeding into adnexal asbscess ? fistula to colon

to cath ovarian artery

use mik- angioD preferred

use CTA to find landmarks and then "fish"

front, back, side to side, investiagte all 360degree of aorta at as many levels as possible

you will finally hit the target

then hold that still and advance micro with GTglide

in this case, i used particles, i suppose you could use whatever

Splenic Artery EMbo for trauma JR style

use cath to get into celiac- likes SIM1 and Sos

use micro to get out into splenic - like 2.8F progreat with preloaded wire - coils are fine through it

decide prox or distal and decide where to start - can do cominbation if really want

to set upa coil pack- use a large coil, sig overized to create a nest - use detachable like interlock

then start shooting in smaller coils, still overized to splenic 1-2 mm to plug up the nest

when do your initial angiograms, may see some bleeding past pack initially but it will likely embolize after time

thats it

other ways to do it

if can get a glidewire out into splenic can consider switching for ampltaz and then advancing 5F sheath into spelnic

then can shut down vessel with nice size vascular plug

then can consider shutting down access site with proglide

Splenic Artery embo: way i did it around 12/2017

cath right groin

5F glide cobra to celiac

2.8F progreat

spin it into the splenic

pick a spot between DPA and PM (dorsal pancreatic and panc magna)

embolize with interlocks - use like 2-3

post embo imaging

thats it

things to think about with embolization, cathereizing small vessels:

use the tRANSCEND wire. theres a reason that DK used it all the time. It works. used it around 6/2018 with great success. of note was using a dubsangle GT glide and it didn't work. you would like hydrophilic wires would be better

GOOD CATHETER TO USE FOR RADIAL ACCESS:

AR2 catheter from cardiology. Good for celiac cath. basically a right angle catheter with the tip ointing straight

Pelvic Congestion Syndrome / Gonadal Vein Embolization

A to Z

as per JR

R neck access

JB1 catheter with glidewire

probe L renal

do renal venogram, ? L gonadal vein reflux

if dont see, still cath L gonadal vein using glide and perform venogram

Eval for ?pelvic varices

If see, start embolization