Sclerosing Agents: Tips & Tricks Session: Liquid Embolics

Transcription

1 Sclerosing Agents: Tips & Tricks Session: Liquid Embolics Jeffrey S. Pollak, M.D. Robert I. White, Jr., M.D. Professor of Interventional Radiology Yale University School of Medicine Department of Radiology and Biomedical Imaging

2 Jeffrey Pollak, M. D. Consultant: Cook Medical

3 Sclerosant Agents Liquid agents causing intimal injury with inflammation and endothelial destruction, thrombosis, & subsequent fibrotic obliteration Examples ethanol hypertonic glucose detergents hot contrast doxycycline OK-432 (Picibanil) bleomycin Ethibloc not FDA approved

4 Sclerosants: Indications General: flow into a space (e.g., vascular bed) targeted for destruction/obliteration Specific examples superficial varices gonadal varices varicocele & pelvic congestion portal hypertensive varices and lobar portal vein low flow vascular malformations high flow vascular malformations arteriovenous fistulae typically small tumors nonvascular (e.g., pleurodesis, lymphocele)

5 Approaches Transvascular/transluminal transarterial transvenous Direct puncture

6 Technique Often, preliminary contrast injection determine volume assess connections to nontarget sites (e.g., normal veins) superficial sites (e.g., varicose veins) can primarily inject sclerosant Administer sclerosant use volume contrast volume prior to opacifying nontarget sites small volume connecting tube fluoroscopic monitoring

7 Visualize agent contrast displacement opacify the sclerosant Techniques Foam with detergent sclerosants ultrasound to check distribution Combine with other embolization agents/devices mechanical devices & occlusion balloon occlude nontarget pathways retain the sclerosant in the target

8 Detergent Sclerosants Fatty acid derivatives Common agents FDA approved for LE vv s sodium tetradecyl sulfate (STS) (Sotradecol) concentrations of 1% and 3% available polidocanol (liquid and foam formulations) Less common sodium morrhuate ethanolamine

9 Detergent Sclerosants Concentration full (STS 3%) or diluted for smaller vessels Maximum doses uncertain, STS & polidocanol recommended <10-15 ml per session May opacify water soluble C or iodized oil Physical state liquid or foam mix with air or CO 2

10 Advantages of Detergent Sclerosant Foam Broad intimal contact Not diluted by blood (displaces it) Prolonged intimal contact Small amount of agent large volume foam Extrav of foam appears less injur than liquid Echogenic for ultrasound guidance more effective intimal injury Like liquid, flows into communicating spaces

11 Teenage girl with painful low flow intramuscular venous malformation in lateral right forearm Persistent despite two prior operations.

12 2 nd direct punct, SP 1 st STS foam Direct puncture venogram Final, SP 3 punctures Contrast displacement total STS foam (echogenic) = 10 ml

13 38 yo woman with painful right medial thigh IM VM Axial T2 fat sat Deep femoral vein Compressible venous space

14 Coil embolization of outflow routes to prevent nontarget sclerosant exposure

15 STS foam injection, displacing contrast pre post Echogenic foam in venous space

16 Varicocele Embolization with Sclerosant & Coils L Sclerosant Coils 1 st coil to limit inferior spread. Sclerosant foam displacing contrast, into upper pampiniform plexus & collaterals extensive intimal damage.

17 50 yo man w chr L > R vcl s & scrotal discomfort Hilar collat with comptnt sup L ISV Microcatheter in tortuous hilar collateral, only to L5 level

18 Opacified sclerosant foam with water-soluble contrast Opacified STS foam in low ISV S/P low ISV STS foam S/P coils & 2 nd STS foam

19 69 yo man with alcoholic cirrhosis and bleeding gastric varices Occlusion balloon to contain sclerosant foam, opacified with iodized oil and air

20 50s man w HCV cirrhosis, ascites, encephalopathy, and now profusely bleeding umbilical varices

21 Direct umbilical vein catheterization AVP2 & STS foam 5 months

22 50s yo woman w dominant outflow L pelvic AVM and pain SP arterial glue and retrograde & direct puncture outflow vein coil embolization. Persistent AVM.

23 Direct vein puncture & STS AVM occluded

24 Detergents: Adverse Events Safer than ethanol. Polidocanol, STS > others Local & regional local pain & swelling adjacent tissue injury appears uncommon skin/mucous membrane ulceration very rare: peripheral neuropathy, muscle injury DVT/PE also uncommon Systemic foam: infrequent fleeting CNS effects stroke/tia very rare in varicose vein studies rarely hemoglobinuria & hemostatic abn s

25 Sclerosant Agents: Conclusions Useful for contiguous spread within a target space with broad surface intimal injury particularly: vascular malformations, varices Detergent sclerosants can be used as foam Value of direct puncture Visualize: C displacement, opacify, US of foam Value of combining with mechanical devices to contain and avoid nontarget exposure coils, plugs, occlusion balloon