768
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Letters to the Editor
Isaacson et al
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REFERENCES 1. Kılıçkesmez Ö, Andıç C, Oğuzkurt L. Delayed failure of rectovaginal fistula embolization with Amplatzer vascular plug 2. Diagn Interv Radiol 2014; 20:511–512. 2. Güneyli S, Çinar C, Bozkaya H, Parıldar M, Oran İ. Applications of the Amplatzer vascular plug to various vascular lesions. Diagn Interv Radiol 2014; 20:155–159. 3. Wilson KA, Haskal ZJ. Durable plug and Onyx occlusion of a refractory bile leak. J Vasc Interv Radiol 2013; 24:1067–1069. 4. Young JA, Shimi SM, Alijani A, Patil PV, Bhat R. Occlusion of a neoesophageal-bronchial fistula using the Amplatzer Vascular Plug 2. Diagn Interv Radiol 2013; 19:259–262.
Coil Embolization to Redirect Embolic Flow during Prostatic Artery Embolization From: Ari J. Isaacson, MD Niraj Bhalakia, MD Charles T. Burke, MD Department of Radiology University of North Carolina 101 Manning Dr. Chapel Hill, NC 27514
Figure 6. Sagittal T2-weighted magnetic resonance image shows the mucinous tumor collection in the lower pelvis, with the occluder device in place (arrow). No fluid is noted within the fistulous tract, and the device remains in place.
Vaginal fistula closure using an AVP is a novel treatment. Traditionally, vaginal fistula closures are performed surgically; however, this patient was not deemed an appropriate surgical candidate. Enterocutaneous fistulas have been closed using the Biodesign Fistula Plug (Cook, Inc), but the fistula in this case was too large for use of this fistula product. A previously published case using the AMPLATZER occluder device (St Jude Medical, Inc) for closure of a rectovaginal fistula was managed similarly (1). However, although initially successful, the treatment failed in the long-term follow-up in that case. The authors suggested that the late failure of the AVP in rectovaginal fistulas may be related to the increase in rectal pressure during the passage of stool and regional movements. In our case, we opted to try the AVP because of the thick consistency of the pseudomyxoma and because of the relative large size of the fistula not amenable to other closure interventions. So far only short-term follow-up is available for our case, and longterm viability of this device for closure of large fistulas is necessary to confirm stability. Since the introduction of AVPs for use in various clinical applications and organ systems, their applicability has been confirmed to be successful in esophagobronchial, gastrocolonic, and ureterovesical fistulas (2–4). Use of the AVP in select patients with vaginal fistulas may prove to be beneficial.
Editor: Nontarget embolization during prostatic artery embolization (PAE) can potentially lead to injury of the bladder or rectum (1). The anterior/lateral prostatic artery (ALPA) or cranial prostatic artery provides blood to the central gland, the portion of the prostate that is enlarged with benign prostatic hyperplasia (BPH) and is therefore primarily targeted. The other main prostatic arterial supply comes from the posterior/ lateral prostatic artery (PLPA) or caudal prostatic artery, which provides blood to the inferior and capsular regions of the prostate, and can be secondarily targeted if the ALPA cannot be catheterized. However, care should be taken when embolizing the PLPA because there are often rectal branches arising from it (2). Arterial anatomic variation to the prostate is commonplace, and one frequently seen variation is a common trunk of ALPA and PLPA resulting in a largerdiameter target vessel (3). Embolization with the catheter positioned in the common trunk may pose the challenge of adequately treating the prostate without sending particles to the rectum, potentially resulting in ischemia. The case described here demonstrates the potential value of proximal coil embolization to redirect particle flow during PAE with a common prostatic artery trunk. Our institutional review board does not require approval for case reports such as this. A 67-year-old man presented with a multiyear history of lower urinary tract symptoms secondary to BPH that None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.12.615
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2015
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Figure. (a) Digital subtraction angiography (DSA) in neutral position demonstrates the common trunk of the prostatic arteries (white arrow), the ALPA (black arrowheads), the PLPA (black arrows), contrast blush within the prostate (black asterisks), and suspected contrast blush within the rectum (white asterisks). (b) Axial cone-beam CT image confirms partial contrast enhancement of the rectum (arrows). (c) DSA image in neutral position demonstrates selective catheterization of the PLPA (black arrows) with communication to the superior rectal artery (white arrows). (d) DSA image in neutral position demonstrates coil embolization of the PLPA (black arrow). The prostatic artery common trunk (white arrow) and the ALPA (white arrowheads) remain patent, with contrast blush seen in the prostate but not the rectum. (e) Axial cone-beam CT image confirms enhancement of the prostate (asterisks) but not the rectum.
770
’
Letters to the Editor
were inadequately treated with tamsulosin. His International Prostate Symptom Score was 18 and his quality of life score was 4 (“mostly dissatisfied”). On preprocedural pelvic computed tomographic (CT) angiography, his prostate was measured as having a volume of 80 cm3, and the ALPA and PLPA were identified bilaterally. On the left, it was noted that they arose from a common trunk without rectal branches identified at that time. During PAE, the left-sided common prostatic artery trunk was selectively catheterized with a 2.4-F Direxion microcatheter (Boston Scientific, Natick, Massachusetts) and a 0.018-inch Glidewire GT (Terumo, Somerset, New Jersey). Digital subtraction angiography demonstrated branching of the common trunk into the ALPA and PLPA with prostate blush and probable rectal opacification (Fig, a). Contrast cone-beam CT was performed with the catheter in the same position, and enhancement of the rectum was confirmed (Fig, b). The PLPA was selectively catheterized, and angiography revealed continuity with the left superior rectal artery (Fig, c). After several unsuccessful attempts at selective catheterization of the ALPA, a small coil (3/2-mm Tornado; Cook, Bloomington, Indiana) was placed in the PLPA to redirect particles through the ALPA. Subsequent angiography and cone-beam CT with the catheter in the common trunk showed contrast agent in the hemiprostate without rectal opacification (Fig, d, e). Embolization of the prostate was then performed with 300–500–mm Embosphere particles (Merit Medical, South Jordan, Utah) until stasis was achieved in the ALPA. Embolization of the ALPA was also performed on the contralateral side. At 1-month follow-up, the patient denied postprocedural rectal bleeding and abnormal stools. His International Prostate Symptom Score had decreased from 18 to 8 and his quality of life score had improved from 4 to 3 (“mixed satisfaction”). His maximum urine velocity increased from 3.1 mL/s at baseline to 5.7 mL/s. Because
Isaacson et al
’
JVIR
the patient was enrolled in a clinical trial, he also underwent anoscopy that demonstrated normal-appearing distal rectal mucosa and a normal anal canal. The risk of major complication as a result of inadvertent rectal embolization during PAE is still uncertain. A case report (1) recently described evidence of ischemic rectitis seen with colonoscopy in a patient who had had undergone PAE 4 days earlier. However, on repeat colonoscopy, the ulcers had resolved 16 days after the procedure (1). In the largest PAE series to date (4), of 250 patients who underwent the procedure, five reported postprocedural rectal bleeding, and all had symptomatic resolution without treatment. No major complications involving the rectum occurred (4). Until more evidence is available to completely alleviate concern for rectal injury after PAE, measures should still be considered to prevent nontarget embolization. The present case demonstrates the potential value of coil embolization to redirect flow of embolic particles away from the rectum during PAE. In other scenarios, this technique may also be beneficial to prevent nontarget embolization of the penis or bladder during PAE.
REFERENCES 1. Moreira AM, Marques CF, Antunes AA, Nahas CS, Nahas SC, de Gregorio Ariza MA, et al. Transient ischemic rectitis as a potential complication after prostatic artery embolization: case report and review of the literature. Cardiovasc Intervent Radiol 2013; 36(6):1690–1694. 2. Bilhim T, Tinto HR, Fernandes L, Martins Pisco J. Radiological anatomy of prostatic arteries. Tech Vasc Interv Radiol 2012; 15(4):276–285. 3. Bilhim T, Pisco JM, Rio Tinto H, Fernandes L, Pinheiro LC, Furtado A, et al. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol 2012; 23(11): 1403–1415. 4. Pisco JM, Rio Tinto H, Campos Pinheiro L, Bilhim T, Duarte M, Fernandes L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23(9):2561–2572.
’
Letters to the Editor
Isaacson et al
’
JVIR
REFERENCES 1. Kılıçkesmez Ö, Andıç C, Oğuzkurt L. Delayed failure of rectovaginal fistula embolization with Amplatzer vascular plug 2. Diagn Interv Radiol 2014; 20:511–512. 2. Güneyli S, Çinar C, Bozkaya H, Parıldar M, Oran İ. Applications of the Amplatzer vascular plug to various vascular lesions. Diagn Interv Radiol 2014; 20:155–159. 3. Wilson KA, Haskal ZJ. Durable plug and Onyx occlusion of a refractory bile leak. J Vasc Interv Radiol 2013; 24:1067–1069. 4. Young JA, Shimi SM, Alijani A, Patil PV, Bhat R. Occlusion of a neoesophageal-bronchial fistula using the Amplatzer Vascular Plug 2. Diagn Interv Radiol 2013; 19:259–262.
Coil Embolization to Redirect Embolic Flow during Prostatic Artery Embolization From: Ari J. Isaacson, MD Niraj Bhalakia, MD Charles T. Burke, MD Department of Radiology University of North Carolina 101 Manning Dr. Chapel Hill, NC 27514
Figure 6. Sagittal T2-weighted magnetic resonance image shows the mucinous tumor collection in the lower pelvis, with the occluder device in place (arrow). No fluid is noted within the fistulous tract, and the device remains in place.
Vaginal fistula closure using an AVP is a novel treatment. Traditionally, vaginal fistula closures are performed surgically; however, this patient was not deemed an appropriate surgical candidate. Enterocutaneous fistulas have been closed using the Biodesign Fistula Plug (Cook, Inc), but the fistula in this case was too large for use of this fistula product. A previously published case using the AMPLATZER occluder device (St Jude Medical, Inc) for closure of a rectovaginal fistula was managed similarly (1). However, although initially successful, the treatment failed in the long-term follow-up in that case. The authors suggested that the late failure of the AVP in rectovaginal fistulas may be related to the increase in rectal pressure during the passage of stool and regional movements. In our case, we opted to try the AVP because of the thick consistency of the pseudomyxoma and because of the relative large size of the fistula not amenable to other closure interventions. So far only short-term follow-up is available for our case, and longterm viability of this device for closure of large fistulas is necessary to confirm stability. Since the introduction of AVPs for use in various clinical applications and organ systems, their applicability has been confirmed to be successful in esophagobronchial, gastrocolonic, and ureterovesical fistulas (2–4). Use of the AVP in select patients with vaginal fistulas may prove to be beneficial.
Editor: Nontarget embolization during prostatic artery embolization (PAE) can potentially lead to injury of the bladder or rectum (1). The anterior/lateral prostatic artery (ALPA) or cranial prostatic artery provides blood to the central gland, the portion of the prostate that is enlarged with benign prostatic hyperplasia (BPH) and is therefore primarily targeted. The other main prostatic arterial supply comes from the posterior/ lateral prostatic artery (PLPA) or caudal prostatic artery, which provides blood to the inferior and capsular regions of the prostate, and can be secondarily targeted if the ALPA cannot be catheterized. However, care should be taken when embolizing the PLPA because there are often rectal branches arising from it (2). Arterial anatomic variation to the prostate is commonplace, and one frequently seen variation is a common trunk of ALPA and PLPA resulting in a largerdiameter target vessel (3). Embolization with the catheter positioned in the common trunk may pose the challenge of adequately treating the prostate without sending particles to the rectum, potentially resulting in ischemia. The case described here demonstrates the potential value of proximal coil embolization to redirect particle flow during PAE with a common prostatic artery trunk. Our institutional review board does not require approval for case reports such as this. A 67-year-old man presented with a multiyear history of lower urinary tract symptoms secondary to BPH that None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.12.615
Volume 26
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Number 5
’
May
’
2015
769
Figure. (a) Digital subtraction angiography (DSA) in neutral position demonstrates the common trunk of the prostatic arteries (white arrow), the ALPA (black arrowheads), the PLPA (black arrows), contrast blush within the prostate (black asterisks), and suspected contrast blush within the rectum (white asterisks). (b) Axial cone-beam CT image confirms partial contrast enhancement of the rectum (arrows). (c) DSA image in neutral position demonstrates selective catheterization of the PLPA (black arrows) with communication to the superior rectal artery (white arrows). (d) DSA image in neutral position demonstrates coil embolization of the PLPA (black arrow). The prostatic artery common trunk (white arrow) and the ALPA (white arrowheads) remain patent, with contrast blush seen in the prostate but not the rectum. (e) Axial cone-beam CT image confirms enhancement of the prostate (asterisks) but not the rectum.
770
’
Letters to the Editor
were inadequately treated with tamsulosin. His International Prostate Symptom Score was 18 and his quality of life score was 4 (“mostly dissatisfied”). On preprocedural pelvic computed tomographic (CT) angiography, his prostate was measured as having a volume of 80 cm3, and the ALPA and PLPA were identified bilaterally. On the left, it was noted that they arose from a common trunk without rectal branches identified at that time. During PAE, the left-sided common prostatic artery trunk was selectively catheterized with a 2.4-F Direxion microcatheter (Boston Scientific, Natick, Massachusetts) and a 0.018-inch Glidewire GT (Terumo, Somerset, New Jersey). Digital subtraction angiography demonstrated branching of the common trunk into the ALPA and PLPA with prostate blush and probable rectal opacification (Fig, a). Contrast cone-beam CT was performed with the catheter in the same position, and enhancement of the rectum was confirmed (Fig, b). The PLPA was selectively catheterized, and angiography revealed continuity with the left superior rectal artery (Fig, c). After several unsuccessful attempts at selective catheterization of the ALPA, a small coil (3/2-mm Tornado; Cook, Bloomington, Indiana) was placed in the PLPA to redirect particles through the ALPA. Subsequent angiography and cone-beam CT with the catheter in the common trunk showed contrast agent in the hemiprostate without rectal opacification (Fig, d, e). Embolization of the prostate was then performed with 300–500–mm Embosphere particles (Merit Medical, South Jordan, Utah) until stasis was achieved in the ALPA. Embolization of the ALPA was also performed on the contralateral side. At 1-month follow-up, the patient denied postprocedural rectal bleeding and abnormal stools. His International Prostate Symptom Score had decreased from 18 to 8 and his quality of life score had improved from 4 to 3 (“mixed satisfaction”). His maximum urine velocity increased from 3.1 mL/s at baseline to 5.7 mL/s. Because
Isaacson et al
’
JVIR
the patient was enrolled in a clinical trial, he also underwent anoscopy that demonstrated normal-appearing distal rectal mucosa and a normal anal canal. The risk of major complication as a result of inadvertent rectal embolization during PAE is still uncertain. A case report (1) recently described evidence of ischemic rectitis seen with colonoscopy in a patient who had had undergone PAE 4 days earlier. However, on repeat colonoscopy, the ulcers had resolved 16 days after the procedure (1). In the largest PAE series to date (4), of 250 patients who underwent the procedure, five reported postprocedural rectal bleeding, and all had symptomatic resolution without treatment. No major complications involving the rectum occurred (4). Until more evidence is available to completely alleviate concern for rectal injury after PAE, measures should still be considered to prevent nontarget embolization. The present case demonstrates the potential value of coil embolization to redirect flow of embolic particles away from the rectum during PAE. In other scenarios, this technique may also be beneficial to prevent nontarget embolization of the penis or bladder during PAE.
REFERENCES 1. Moreira AM, Marques CF, Antunes AA, Nahas CS, Nahas SC, de Gregorio Ariza MA, et al. Transient ischemic rectitis as a potential complication after prostatic artery embolization: case report and review of the literature. Cardiovasc Intervent Radiol 2013; 36(6):1690–1694. 2. Bilhim T, Tinto HR, Fernandes L, Martins Pisco J. Radiological anatomy of prostatic arteries. Tech Vasc Interv Radiol 2012; 15(4):276–285. 3. Bilhim T, Pisco JM, Rio Tinto H, Fernandes L, Pinheiro LC, Furtado A, et al. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol 2012; 23(11): 1403–1415. 4. Pisco JM, Rio Tinto H, Campos Pinheiro L, Bilhim T, Duarte M, Fernandes L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23(9):2561–2572.
