Ethylene-vinyl alcohol polymer transarterial embolization in emergency peripheral active bleeding

Transcription

1 Ethylene-vinyl alcohol polymer transarterial embolization in emergency peripheral active bleeding Ierardi AM, Duka E, Micieli C, Carrafiello G Interventional Radiology Unit University of Insubria, Varese (IT)

2 Anna Marie Ierardi, MD No relevant financial relationship reported

3 Background Once a patient arrives in the interventional radiology suite, it is important to move efficiently to start, perform, and complete the procedure as quickly as possible to avoid the development of the lethal triad of hypothermia, acidosis, and coagulopathy. Severely traumatized and unstable patients will usually require the assistance of the anesthesia service to manage the airway and conduct the ongoing resuscitation of the patient.

4 Background Ethylene vinyl alcohol (EVOH) copolymer (Onyx; ev3 Endovascular, Inc, Plymouth, Minnesota) is a liquid embolic agent that was approved by the US Food and Drug Administration for the treatment of cerebral arteriovenous malformations in 2005.

5 Background Directions for use Shake Onyx at least 20 minutes on a mixer Injection slow, steady rate 0.1 ml/min; do not exceed 0.3 ml/min ( vasospasm) Premature solidification of Onyx may occur if microcatheter contact any amount of saline, blood or contrast Use only DMSO compatible device Adequate sedation is needed throughout the embolization procedure

6 Background Features Embolic agent can be injected through a very small catheter and then solify to occlude a larger space Can flow into complex vascular structures Deep penetration of the target Very efficient occlusion Onyx immediately forms a skin as the polymeric embolus solidifies from the outside to the inside Save time and money?

7 Onyx & Emergency Sounds strange!!

8 Onyx & Emergency

9 traumatic bleeding of a renal angionyolipoma

10 Onyx & Emergency embolization time

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12 Purpose to evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, CA, USA) as the primary treatment in active peripheral emergency arterial bleeding.

13 Materials and Methods (1) Between January 2014 and June 2015, 120 patients with active peripheral arterial bleeding who were treated by embolization were retrospectively analyzed. We selected 55 (age year old) patients embolized with Onyx, chosen as embolic agent in an intention-to-treat fashion. Multidetector computed tomography (MDCT) was performed in all patients.

14 Materials and Methods (2) Active bleeding was detected in all cases. Digital subtraction angiography (DSA) confirmed CT findings in all cases. The causes of bleeding were: traumatic in 28 pts, bowel angiodysplasia in 12 pts, duodenal ulcer in 3 pts, chronic pancreatitis in 2 pts anticoagulant therapy in 10 pts. Twenty-two (22/55) patients were under anticoagulant or antiplatelet therapy. Embolization was possible in all patients.

15 Results Technical success rate was 100%. Immediate bleeding control rate was 100%. No rebleeding at 30 days occurred in 54 pts (98.2%). Only a reperfusion of a gastroepiploic artery was observed and retreated with a second embolization. There were no major complications, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 12 months (range, 6-24 months).

16 Splenic bleeding in a young woman with pancreatitis

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18 Bleeding of a colic angiodysplasia

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20 versus conclusions Thanks to the physical properties a controlled and precise release of the embolic agent can be achieved in order to have a target distal embolization of the bleeding sites. The homeostatic power of Onyx not influenced by the patient s coagulation status represents one of the major advantage in compromised patients. We never registered ischemic damage of the bowel requiring surgery: we hypothized a decrease of blood flow more than a complete occlusion especially when Onyx does not make the cast in the vessel.

21 Conclusions Control of massive active peripheral emergency arterial bleeding using superselective embolization with Onyx is feasible and safe. A more liberal use of Onyx in academic institutions could be done to provide the opportunity for future interventionists to be trained. Studies about costs are in progress.

22 THANK YOU Unit of Interventional Radiology, Varese Hospital, Italy