3. +
Intro
n Hemorrhage is the 3rd cause of death in neoplastic disease (after tumor invasion
on organ function and infection). Bleeding occurs in up to 10 % of patients with
advanced cancer and can take different forms.
n Apart from interventional procedures, the endovascular hemostatic embolisation
is performed in emergency and can be practice:
- to treat hemorrhage uncontrolled by medical treatment in a cancer kwowned
- after diagnostic and therapeutic procedures .
- to reduce morbidity and mortality compared to surgery procedures
4. +
Hemorrhage causes
n Blood vessels (capillaries or bigger vessels) affected by cancer
n Thrombocytopenia (being or not iatrogenic) leading to bleeding,
especially when an infection occurs.
n Abnormal low level of coagulation factors (intravascular coagulation)
5. +
Goal and principle
n Goal of embolization: to reduce/stop the blood flow into the vessel to stop
haemorrhage
n Occlusion site: proximal distal capillary
n Material: catheter and microcatheter
n Choice of embolisation: agent depends largely regarding the indication .
6. +
Urgent embolisation process
n Evaluate effectively and precisely the clinical situation
n To assess life threat prognostic as well as risks and
benefits
n Identification of the site of the damage using an
angioscanner
n Investigate material availability
n Multidisciplinary care
n Inform the patient and family
7. +
Identification bleeding site
CT 3 phases : unenhanced et contrast-enhanced arterial and veinous
phase
High attenuation > 90 UH seen in arterial phase and growing in
veinous phase
No oral contrast
Active contrast material extravasation
seen in CT if >0,3 ml/min
Active contrast material extravasation
seen in angiography if > 0,5 ml/mn
Kuble 2003
8. +
Identification bleeding access
Less irradiation time, more selective catheterism, easier work
Active contrast
material extravasation
Calcifications right
iliac arteryè prefer
left access
9. +
n Hematuria
n Hemoptysis
n Epistaxis
n Hemoperitoneum
n Hematochezia
n Other concerns
n Post biopsy procedure ,post surgery, post radiotherapy,…
n Post-ponction intervention
n Soft tumor tissus …..
Clinical scenarios
10. +
Embolisation agents
3 types
§ Mecanical occlusion devices: Coils/Plugs
- Equivalent of surgical ligation
- Mechanic occlusion and fibres attached to them causes thrombosis
- Occludes arteries proximally while preserves distal flow via
collaterals vessels
- Don‘t cause complete organ infarction
§ Particulate embolic agents: PVA/microspheres/Gelfoam
Inflammatory reaction involving vessel wall
Flow downstream until they blocked in vessel
§ Liquid embolic agents: Nbutyl2 cyanoacrylate, isobutyl2cyanoacrylate
- Rapidly hardening adhesives
- Necrosis and thrombosis
- Rapid polymerization in contact with ionic media
13. +
Synthetic Glue
Cyano: link
Acrylate : polymerisation
N-Butyl-2-cyanoacrylate:Histo-acryl®
Methacryloxysulfolane : Glubran 2®
• Good contrast with lipiodol
• Low viscosity
• Catheter be flushed with dextrose before injection
• Occlusion by polymerisation
• Allergy like a external particle
• Need practice ++
14. +
Gelatin sponge
• Hemostypticum
• First endovasc use (1964) in occlusion
of a carotid-cavernous fistula
(speakman)
• settings
- Cut in pledgets
- Made into a slurry
- Powder or particles
• temporary agent
• Aggregation
• Biologically inert manner
• Recanalisation in 2-14 days
15. +
Coils
n Non fibred-: less used
n Fibred : helicoidal mono ou biconic
n Different shape
n Hydrocoil
n Push coils
n Controlled-detachable
n Precised site
22. +
Anatomy well known
anatomic variants
Interconnection arcades
Only embolisation of coronar stomachic and
gastroduodenal arteries are safe ;
for all others inconnection → necessary to be
hyperselective to avoid necrosis
23. +
n Mr X., 69 years old , Jehovah’s witness
n adressed in emergency for management aggressive gastric
lymphoma
Endoscopy important ulcer and
necrotic lesion in the bulb
24. +
n Massive upper abdominal hemorrhage ( >1/2 l )
n blood pressure 47, violent abdominal pain .
n cannulation with macromolecules, perfusion, anxiolytic, painkillers
n Risk of upcoming death by hemorrhage without transfusion.
n Refusal of blood transfusion.
n Hemostasis embolization
Mr X., 69 years old , Jehovah’s witness
30. +
Explore all
1. Coeliac trunk
2. Splenic artery
3. Gastroduodenal artery
4. Common, proper hepatic artery
5. Pancreatic arcade
6. Superior mesenteric artery
7. and mesenteric branches
• Look for - extravasation , active blood leak,
- hematoma
- erosion
- pseudoanevrysm
• Look for unusual site
31. +
Hemorrhage post pancreatic surgery
n gastroduodenal strump embolization
n Sometimes use of cover stent
n If no lesion : discussion with surgeon to decide a systematic embolisation
n Not targeted embolisation make risk of recurrence ( Hur et all JVIR 11 )
Stump gastroduodenal artery
33. HCC complicated by rupture in 10-15 %
High mortality rate within 30 days
Active bleeding
HCC
bleeding
Portal thrombosis
34. +
Mr ,65 years old , hepatic angiosarcoma diagnosed in march 2013 and treated
since with Paclitaxel.
Large multilocular tumor
Life-threatening hemorraghe due to the tumor
Hepatic haemorraghe
36. +
Most often iatrogenic injury
cause massive hemorraghe
First choice embolization
Epigastric artery
37. +
Massive hematuria
n rare episode in case of urothelial carcinoma+++ : bladder, renal cavities
n After renal biopsy
n Selective embolisation for control of hematuria secondary too advanced
cancer
n As symptomatic process to improve quality of life
and for palliating hematuria and preventing anaemia ….
n Improve survival ( several months)
39. +
Left renal cancer
- 1 superior artery vascularise tumor with
vertical branch (FAV)
- 2 inferior artery : horizontal branch ènormal
kidney
vertical branch ètumor
1
2
40. + Coils
8x20 mm ;3x14 mm ; 4x7 mm
Particules de 700-900 µ
Coils 4x7 mm ; 6x7 mm
Tumoral devascularisation
41. +
Hematuria post renal biopsy
Fistula between artery and pyelon
Embolisation of arteries feeding fistula
Stop bleeding
Rarement
42. + Massive hemoptysis
n 300–600 ml blood loss per day
n Mortality rate ≈ 64 % at one year ( Garcia 2014)
n Airway maintenance is vital more important than blood loss
n Causes : bronchogenic carcinoma (superficial mucosal invasion
erosion into blood vessels and necrosis)
n Others : lung carcinoid tumor , metastasis from breast, renal ,and
colon cancers
n Other ++: aspergillus , mucormycosis in patients with
immunodeficiency (after chemotherapy)
n More rarely , hemoptysis after treatment (laser, curietherapy)
44. +
Embolisation 500/700 µ embospheres by microcatheter
Mr G, 68 years old
1. non resorbable particles> 350 𝝁𝒎 appeared to reduce the risk of
spinal complications since they are too large to be used for
embolisation of small vessels supplying the spine (Ittrich 2015)
45. +
Massive hemoptysis
n Knowledge of the bronchial artery anatomy, variabilite, ectopic arteries ,
dangerous anastomoses
n Before : chest CT angiography look for supply arterial systemic anastomoses
(Adamkiewicz ) embolisation
n Meanwhile : control lake of reflux
n After : control stop arteriel flow in treated artery
• Survival better if hemoptysis non correlated to tumor
• Prognosis remains poor
46. +
variability
Aberrant origins
n subclavian artery
n thyrocervical trunk
n internal thoracic artery
n aortic arch,
n coronary arteries
Artère Adamkiewiecz
n Arise from T5 - L4
n Rarely from right
intercostobronchial trunk
Dangerous bronchopulmonary anastomoses
• Coronary artery
• Subclavian artery
• vertebral artery
• anterospinal artery
47. +
n Mr C. massive epistaxis with pulmonary emboly under anticoagulant
therapy
n right pneumonectomy for cancer a few weeks ago
n bilateral bleeding treating by anteropostero tamponnade applying
dual ballons in nose cavities inefficient
n Indication of supraselective embolisation right and left spheno-
palatine arteries ( variable number of anastomoses between internal
and external carotid arteries)
Epistaxis
48. superselective embolisation with microsphere
200 to 400 microns in both spheno-palatine
arteries
massive bilateral epitaxis with risk of death.
Left
Right
49. +
Epistaxis
n Frequent event during chimiotherapy responsible myelosuppression
for acute leukemia , rarely dangerous for life , stopping
spontaneously or manual bidigital compression anterior meshing or
endoscopic electrocoagulation
n Posterieur epistaxis posterior tamponnage in pharyngoscopy.
n ethmoïde tumor bleeding: surgery or embolisation.
50. +
Coils: tips and tricks
n Choice coil : fonction of vessel size to exclude (oversizing)
: long coil for high volume
n Embolisation with 4,5 F (0,0038) : use coils 0,035 ou 0,038
n Embolisation with microcatheters 0,24 max use coils 0,018
n Always rinse microcatheter or catheter 5F before entering coil into them
precautionary injection to control ,upstream embolisation
51. +
Results
n Success or control in 80 à 100 % cases.
n Authors point at the need to act rapidly and to prevent any further delays in treating by
surgery if embolisation procedure is too difficult or too long or insure of bleeding site
n Recurrence : 0-33 % (abdominal )
n Many material used alone or in association
n Coils : recanalisation described as classic process ( Sigler et all, Salamat M. et all)
n Spongel low clinical success < 65 %
n glue : high clinical sucess > 90 % ( Lee 2007 , Jae 2007)
n High sucess rate
n Recurrence more likely
52. +
Evolution ?
n Variety of embolisation agents
n Variety of catheters and microcatheters
n Technology evolution
55. 2D 3D logiciel
Deschamps F. et al CVIR 2010
Sens.3D >2D ( 73% vs 64 %,p=0,036)
Sens.logiciel >3D (93%vs 73 %,p=0,005)
Correlation between observator : 2D (54%),3D(62%),logiciel(82%)
56. +
Post embolisation
n Intensive supervision
n Desilet catheter introduction non removed
n clinical monitoring
n Control imaging
n post embolisation pain ‘monitoring : antalgic protocol
57. +
Conclusion
n Interventionnel radiologist may be able to answer to emergencies
n To know embolisation technics and different agents
n Don’t run but think carefully before you act
n Effective tools
n Non exhaustive equipment
n pluridisciplinary management