Fabrizio Fanelli – Francesco Florio

1. Miami, January 16-20, 2011 ENDOVASCULAR TREATMENT OF ACUTE HEMORRHAGE ItalianVascular and InterventionalRadiology Society Fabrizio Fanelli – Francesco Florio

2. Surgery in acute bleedingpatientshas high • mortality and morbidityrates • Embolizationis a wellestablishedtechnique • 81-93% clinical success • 10-30% rebleeding Eriksson LG - JVIR 2008; 19: 1413-8 “Sapienza” - University of Rome

3. Surgery in acute bleedingpatientshas high • mortality and morbidityrates • Embolizationis a wellestablishedtechnique • 81-93% clinical success • 10-30% rebleeding Dedicated service with expertise and infrastructures Eriksson LG - JVIR 2008; 19: 1413-8 “Sapienza” - University of Rome

4. Trauma • Tumor • Vascularmalformations • Iatrogenic Clinicalsigns BP Pulse Hb “Sapienza” - University of Rome

5. Action • Controlofhemorrhage • Maintainbloodsupply • Vascularrepair • Preventionofinfection • Speed “Sapienza” - University of Rome

6. Action • Controlofhemorrhage • Maintainbloodsupply • Vascularrepair • Preventionofinfection • Speed “Sapienza” - University of Rome

7. Diagnosis • Endoscopy • Labeledredbloodcellscintigraphy • CT • DSA - Anti-peristalticagents - Breathing - Powerinjection - Multiple orientation - Selectivecatheterization - Delayed and native images “Sapienza” - University of Rome

8. Scheffel et al. - Eur Radiol. 2007: 17,1555-65 “Sapienza” - University of Rome

9. Scheffel et al. - Eur Radiol. 2007: 17,1555-65 “Sapienza” - University of Rome

10. Courtesyof J. Golzarian “Sapienza” - University of Rome

11. DSA • Directsigns • extravasation – stagnantcontrast media • Indirectsigns • vessel irregularity • pseudoaneurysm • spasm • earlyvenousreturn • neovascularity • hyperemia • hypovascularity “Sapienza” - UniversityofRome

12. SuspectBleeding CT ActiveBleeding NO ActiveBleeding ClinicalSurveillance DSA “Sapienza” - University of Rome

13. Diagnosticcatheters • Guidingcatheters • Microcatheters • gelfoam • embolicparticles • calibratedembolicparticles • microcoils • coatedcoilshydrogel-coated • detachablecoils • liquidagentsn-butylcyanoacrylate (n-BCA) • Onyx • covered stent “Sapienza” - University of Rome

14. Materials for GI Embolization “Sapienza” - University of Rome

15. M.R., 73 y, Male Patient under antiplatelettherapyfor cv disease Acute bleedingfromanomentalbranch “Sapienza” - University of Rome

16. Hb: 6.2 mg/dl Pulse: 120 b/m PA: 90/60 mmHg “Sapienza” - University of Rome

17. Progreat 2.7 Fr. Microcatheter (Terumo) “Sapienza” - University of Rome

18. Onyx 34 (EV 3) Progreat 2.7 Fr. Microcatheter (Terumo) “Sapienza” - University of Rome

19. Onyx 34 – 3cc (EV 3) “Sapienza” - University of Rome

20. In mostcasesthechoiceofembolicagentdepends on thepositionofthemicrocatheterandthesituation ! - considertheriskofbackflow/retrograde flowrestitution coils>> PVA > glue - considertheriskofbowelischemia coils< PVA << glue “Sapienza” - University of Rome

21. Position of the Microcatheter • In the mesenterium • - Proximally: first tolast-but-onearc • - Distally: the last mesentericarc • between middle and leftcolonicartery: • marginalarteryofDrummond (closeto • bowel) “Sapienza” - University of Rome

22. Position of the Microcatheter • In the mesenterium • - Proximally: first tolast-but-onearc • - Distally: the last mesentericarc • between middle and leftcolonicartery: • marginalarteryofDrummond (closeto • bowel) “Sapienza” - University of Rome

23. Position of the Microcatheter • In the mesenterium • - Proximally: first tolast-but-onearc • - Distally: the last mesentericarc • between middle and leftcolonicartery: • marginalarteryofDrummond (closeto • bowel) “Sapienza” - University of Rome

24. Position of the Microcatheter • In the mesenterium • - Proximally: first tolast-but-onearc • - Distally: the last mesentericarc • between middle and leftcolonicartery: • marginalarteryofDrummond (closeto • bowel) • In the bowelwall • - Vasarecta “Sapienza” - University of Rome

25. P.V., 55 y, Female antiplatelettherapyfor cv pathology Nastyspillwhileskiing “Sapienza” - University of Rome

26. P.V., 55 y, Female antiplatelettherapyfor cv pathology Nastyspillwhileskiing 24h feeling suddenlyunwell, hypotension HB: 6.5 mg/dl PA: 80/50 mmHg Pulse: 130 b/m “Sapienza” - University of Rome

27. P.V., 55 y, Female antiplatelettherapyfor cv pathology Nastyspillwhileskiing 24h massive bleeding and markedHbreduction “Sapienza” - University of Rome

28. SMA “Sapienza” - University of Rome

29. Microplex 18 detachablecoil (MicroventionTerumo) Progreat 2.7 Fr. Microcatheter (Terumo) “Sapienza” - University of Rome

30. GI Bleeding • Ceckboth SMA and Celiac • Look for “back door” • Ceckarterialdiameter • Watchforcollaterals “Sapienza” - University of Rome

31. Celiac • GI Bleeding • Ceckboth SMA and Celiac • Look for “back door” • Ceckarterialdiameter • Watchforcollaterals “Sapienza” - University of Rome

32. Celiac • GI Bleeding • Ceckboth SMA and Celiac • Look for “back door” • Ceckarterialdiameter • Watchforcollaterals “Sapienza” - University of Rome

33. HydroCoilHydratationControl Whenplaced in a bufferedsolutionlikeblood, the hydrogenleaves the gel whichgraduallyallowsuptakeof water into the polymermatrix (5 min) resulting in expansion. Progreat 2.7 Fr. Microcatheter (Terumo) Azur – Hydrocoils – 0.18” (Terumo) “Sapienza” - University of Rome

34. “Sapienza” - University of Rome

35. Recurrence 10 – 30 % • Coagulationdisorders • Transfusion > 6 pack • Technique • - levelofembolization • - collateralpathway • - choiceofembolic material Poultsides et al. - Arch Surg 2008; 143: 457-61 “Sapienza” - University of Rome

36. Conclusions • The widespreaduseofnewtoolswillleadto a • paradigmshift in the way thesechallengingcases • are managed • CT can beconsidered a validtoolfor the diagnosis • and mustbeperformed in case ofsuspectbleeding • Negative angio and recurrencemaybereducedwith • appropriate technique and selectionof the materials “Sapienza” - University of Rome

37. www.radiointerventistica.org fabrizio.fanelli@uniroma1.it