VOL.
No.
125,
3
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POLYVINYL
By
S. MURTHY
ALCOHOL EMBOLIC
TADAVARTHY,
M.D.,
(IVALON)-A MATERIAL*
JAMES
H.
MOLLER,
MINNEAPOLIS,
NEW
M.D.,
KURT
and
AMPLA’I’Z,
M.D.
MINNESOTA
ABSTRACT:
Successful nonsurgical treatment of gastrointestinal bleeding and arteriovenous malformations by embolization techniques has been previously documented. i) Compressed Ivalon sponge was found to be a suitable embolic material in animals and in four patients. 2) The material has been extensively used in surgery, and its biocompatibility has been proved. 3) Expansion of the compressed sponge to its original size after embolization makes this material extremely effective. Recanalization did not occur in animals and humans. ) For the occlusion of larger arteries, Ivalon can be wrapped around the guidewire. Ivalon sponge absorbs blood and serum, unwraps itself allowing withdrawal of the guidewire. ) Embolization procedures are not without risk since reflux of embolic material may occur. Therefore, these procedures have to be carried out lJnder fluoroscopic control. T is the purpose of this communication to report the experience with a synthetic embolic material which can be introduced through catheters in the management of gastrointestinal bleeders, arteriovenous malformations, hemangiomas, and traumatic rupture of blood vessels. Ivalon sponge, previously used extensively in surgery, has proved to be a good synthetic embolic material.
is dried and becomes hard, it retains its compressed shape. If placed into an aqueous medium as blood, the compressed sponge resumes its original uncompressed shape as seen in Figure I . The compressed sponge
mm
Ivalon, a polyvinyl alcohol, is converted into a sponge-like material by foaming agents and hardened with formaldehyde. It has been used as an ion exchange resin since this foam is a negatively charged colloid and strongly adsorbs cations. Ivalon is also well known to housewives who use it as a cleaning sponge. Polyvinyl alcohol foam has the ability to absorb water; and it is, therefore, used in industry for electroplating and photography. The material is inert and withstands the action of dilute acids, strong alkalis, and common detergents. Ivalon sponge has the unique property of being resilient and readily compressible when wet. If the compressed *
From
the Department of Radiology, University
work
was
supported
in part
by
USPHS
Grant
T12
HE
length
: .
material
after
being
expanded
to
soaked
in
.
1’
FIG. . figure being
of Minnesota i
Ivalon
in
saline. This excellent plastic memory makes this material particularly attractive for embolization procedures where the size of the embolus is always limited by catheter size.
BACKGROUND
This
long
mm
23
Hospitals, 5853
609
and
Compressed Ivalon expanded six times soaked in saline. Minneapolis,
2
Pol HE
06314.
Minnesota.
at the bottom as seen on the
of top
the after
S. M.
6io
J.
Tadavarthy,
H.
Moller
and
K. Amplatz
NOVEMBER,
5975
mensions
can be reduced by a factor of : I. If dried, the compressed material will retain its shape in spite of gas sterilization. If introduced into the blood stream, it will swell and resume its original shape. Ivalon sponge was soaked in heparin and
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10-15
j,-__
FIG.
2.
Ivalon
ethylene
plugs 240
in pre-loaded
tubes
ready
Clay
Adams
poly-
compressed
for gas sterilization.
in
a vice
and
dried.
One
half
to
mm diameter plugs were cut from the dried material with a hole punch similar to a cork borer or the instrument used to cut side holes on angiographic catheters. These I
PREVIOUS
USES
OF
IVALON
Ivalon sponge has been extensively used in experimental animals as a filling material following pneumonectomy. Autopsy examination revealed that Ivalon sponge is inert and readily invaded by fibrous tissue with a minimal amount of inflammatory cells.5 In 1949 it was first introduced for medical use by J. H. Grindlay5 at the Mayo Clinic. When it was used as a skin graft in experimental animals,7 microscopic examination revealed minimal cellular infiltration. In the 1960’s Ivalon was used as a skin substitute in patients with burns. Because of the pores in the foam, it was permeated with serum and adhered to the skin in one or two days. This material appears to serve as a scaffold for ingrowing connective tissue and becomes an integral part ofthe body. The sponge was also advocated for surgical treatment for rectal prolapse.3 Very recently Porstmann et al,9 used this material for nonsurgical closure of patent ductus arteriosus with excellent results. Polyvinyl alcohol sponge was the synthetic material of choice in the early days of cardiac surgery. The first surgical closure of septal defects in this institution was accomplished by this material; it was used for the reconstruction of the mitral valve in cases of mitral insufficiency, as reported by others.’ Although it was used for the repair of aneurysms, increasing rigidity with time made it necessary to replace it by more pliable and long lasting plastics such as dacron and teflon. However, the biocompatibility of Ivalon sponge has been well established.6 The Preparation of Ivalon Emboli. Ivalon plastic foam is highly compressible in the dry or wet stage. If the material is soaked in
heparin
and
compressed
in a vice,
its
di-
plugs
measured
a
few
mm
in
length
(Fig. Ivalon
pre-loaded in small plastic 2). Depending upon the size plugs, either Clay Adams 240
could
be
were
used
as
pre-loaded
tubes
and
tubing of the or
and
260
gas
sterilized. Care must be taken that only gas sterilization and no steam is used. Otherwise, the compressed plugs will cxpand due to absorption of water and will not be suitable for injection through catheters. At the time of embolization, the pre-loaded tubes are connected to the catheter, and the plugs are flushed into the catheter and blood vessel by forceful manual saline injection. It is very important to eliminate all constrictions between the loading tubes and the selective catheter
FIG.
3.
Selective
renal
Ivalon
angiogram
embolization.
of
a
dog
prior
to
VOL.
since rather these Downloaded from www.ajronline.org by 129.97.124.143 on 02/10/15 from IP address 129.97.124.143. Copyright ARRS. For personal use only; all rights reserved
No.
525,
Polyvinyl
3
the compressed rapidly, making emboli difficult. ANIMAL
The renal with Ivalon. 72
hours
Ivalon prompt
(Ivalon)-A
Ivalon
were was
embolized performed
embolization
of the
clots,
611
and
I,.
‘
#{149} 14 ‘
I.
re-
renal
(Fig.
ofrecanalization
autogenous
Material
EXPERIMENTS
obstruction
evidence
Embolic
plugs swell delivery of
artery with 3 ; and ). Aortography performed one week postembolization revealed occlusion of the renal artery at its most proximal portion due to antegrade thrombosis. The dogs were sacrificed at the end of seven days, and the renal artery and kidneys were subjected to histologic examination. The gross specimen of kidney revealed thrombosis of the main renal artery (Fig. ). Histologic cxamination of the canine renal cortex revealed thrombosis of several renal arteries and noncanalization. The renal cortex showed several areas of hemorrhagic necrosis due to thrombosis of the intrarenal arteries. The problem of lysis and fragmentation which is commonly encountered with no
New
VI
arteries ofdogs Angiography
post
vealed
Alcohol
therefore,
does
not
1 .-.,
#{149}
j 5. The gross specimen reveals thrombosis as by arrow.
of the canine
FIG.
pointed
out
in
renal
artery
this
figure
exist.
This drawback has been well documented by several authors,2”#{176} both in humans and
,
‘#{149} Wm#{149}
I
It is very important to and inject the emboli as close to the lesion as possible. Otherwise, the possibility exists that embolic material may enter other arteries resulting in embolic infarctions. Furthermore, it is cxcanine
selectively
experiments. catheterize
tremely
important
that
the
emboli
are
in-
jected through
slowly, particularly after the flow the artery has decreased. If injection is performed rapidly, embolic material may reflux and embolize other arteries. This has been shown in our laboratory where the renal artery was successfully embolized by Ivalon plugs. At the time of post mortem, however, additional emboli were found in the contralateral renal artery. The gross specimen of the target kidney shows extensive hemorrhagic infarction
FIG. 4. Selective embolization renal
artery
renal reveals (arrow).
angiography complete
72
thrombosis
hours
‘‘V,
due
i
ney post-
of the
to embolization. revealed
The several
contralateral kidareas of infarction catheter was well in
(Fig.
6). Since
the
place
at the
of embolization,
that
the
time
embolization
of the
it is likely contralateral
6i
S. M.
2
f
J.
Tadavarthy,
H.
i..
Moller
and
rapidly
in size
sixteen
months.
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open as
K. Amplatz since of
tion
was
the
At
that
tion
of
a
liver
vealed
a huge
few
injected
emboli
age
oi
an
diagnosed treated
by
February,
1974,
transferred
to the for
as soon
Uni-
considera-
as a donor
be-
angiography
and
vascular
which
of the liver.
hepatic foci
stayed for
was
a candidate
supply-
7). Numerous
(Fig. opacified
evidence
re-
artery for
a
arteriovenous
long
shunt-
ing.
This prior
comparatively
was was
Hospitals
spaces
patient
plantation.
renal artery was due to reflux by a too forceful injection. One of the major advantages of this material is expansion to its original size upon exposure to blood. If the sponge is precompressed io: i, the plug will resume its original proportion after it has been embolized. At the time of embolization, therefore, there is a gradual decrease of flow due to complete obstruction of smaller arteries due to the expansion of the injected Ivalon emboli plugs. This gradual expansion of the embolic material results in a very effective and rapid occlusion of the arterial tree, as evidenced in animal experiments where
in
he was
liver
without
time
out
Abdominal
multiple
vascular due to kidney to force-
which
transplant
available.
ing
was totally infarcted selective embolization. In the contralateral ( arrows), certain areas were infarcted due ful injection of embolic material.
liver
Minnesota
came
the
he had
1973,
involvement
time
of
at
1975
However, his abdomen conin size; and a second explora-
diffuse
versity
kidney
noted
He
carried
revealed
FIG.6.Theright
was
January,
hemangioendothelioma.
radiation therapy. tinued to increase
L.
it
In
biopsy
NOVEMBER,
Decrease to
surgery
Ligation
in
thought
was
of the
hepatic
but due to the artery
was
Therefore,
large size not readily
it
was
for
the
liver
trans-
size
of
the
to
be
essential.
artery
was
liver
proposed;
of the liver, the hepatic accessible by surgery.
decided
to
attempt
trans-
resulted
in complete and rapid thrombosis of the superior mesenteric artery. Ten dogs were subjected to embolization of various arteries. Recently, barium impregnated Ivalon plugs have become commercially available, rendering the embolic material visible by roentgenography. At the present time, our experience is limited to non-opaque Ivalon. Another way to make Ivalon plugs radiopaque would be the incorporation of a stainless steel bead. REPORT CASE
male
I.
with
OF
FIG. 7. Selective hepatic artery
CASES
N. 0. is a four and one-half a liver
tumor
which
year has
old
grown
huge
liver
identified
hepatic angiogram and multiple feeding
mass. without
Numerous arteriovenous
vascular
reveals vessels spaces
shunting.
a large to the were
VOL.
catheter patic
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No.
125,
small
peripheral
hepatic
affected. It was,
hepatic
artery
therefore,
strainless
steel
branches,
would
have
decided
umbrella
to
which
613
cutdown
of
hepatic
artery
three
stainless
through
the
as
left
steel
the
catheter.
through
the
small
nylon
bristle
brushes
catheter
using
Ivalon seemed
to
brushes
and the
the
metal
of
flow through as evidenced
the
patient
tion
with
The and
were
placed
small
emboli
umbrellas, were
two
delivered
(Fig.
umbrella.
procedure
there
to showed rise
of
At was
the embolized by angiography.
material t throm
acted bus
the
the
and nylon
embolization to
______J
nidus
units,
funcwhich
ultimately returned to #{231}o units, his bilirubin rose as high as mgm but declined to 2.3 mgm. Shrinkage of the liver by approximately cm above the pubis was noted, but he developed more ascites and his abdominal girth
umbrella
did A
not change. follow-up
angiogram
vealed
complete
occlusion
at
its
origin
to the liver the aorta
(Fig.
9).
at the site
of the flow to branches
The collateral
pooling
of
he was had
a blood
and
received
massive in
to
became
of less
be
right
and
store At
glycogen. autopsy
the
a
tumor
replaced
tumor
was
to hepatic
soft arterial
It
that large
the
and
to
of was
nodular
necrotic embolization.
to
percent
glucose.
his
liver
the
found
was
A
field
felt
of
his
entire
was
lung
because
fact
di-
lethargic
io mgm
upper
metastatic.
hypoglycemic
intake
He
than
infusions
the
dem-
markedly
admission
arrest.
sugar
found
last
directly arteries
to be extremely
a respiratory
have
collateral
previously
was
his
noted
artery
of
in the
re-
1974,
hepatic arising phrenic
spaces
morning
hospital,
April,
branches inferior
vascular
minished. On the
in
of the
demonstration via and
Venous
onstrated
thought
constructed the stainless
with
flow from
nodule
FIG. 8. Guidewire (A) with specially blunt knob that was used to advance umbrella (B) and nylon brush (C).
artery
(arrow).
from
and
C
of hepatic
the liver was maintained via unnamed the aorta and inferior phrenic arteries.
no ar-
procedure, of liver
720
stainless
practically hepatic Obviously
9. Thrombosis
FIG.
comple-
as an excellent formation.
deterioration SGOT
via
8).
emboli were then delivered pile up at the site of the
blood tery
subsequen Subsequent
the
steel
a guidewire
tion
foreign
artery.
catheterized,
Since
pass
ad-
was inserted
umbrellas
could
a be
the catheter, enibolic ma-
brachial
selectively
un-
construct
with the guidewire through serving as a baffle for the injected terial (Fig. 8). The No. 7 French teflon catheter
for
Material
but
been
could
vanced
the
Embolic
was
main
via
New
embolization. Since the hehuge, injection of small emboli not be used in this case. The injection of emboli would have resulted in obstruction
of a few
the
(Ivalon)-A
Alcohol
arterial
artery
could small
Polyvinyl
3
was
that
he
poor
oral
unable
to
reddish-brown
liver.
A
possibly The
portion
of
secondary final
diag-
nosis was hemangiosarcoma of the liver with rnetastases to the lungs. Pathological examination of the common hepatic artery shows the stainless umbrellas, nylon brushes, and the spongy material, namely polyvinyl alcohol (Ivalon) (Fig. io). There was no distal em-
S. M.
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614
J.
Tadavarthy,
H.
Moller
FIG.
and
Selective
I 2.
artery FIG. 10. artery
Postmortem examination of the hepatic reveals thrombosis. The arrows point tothe stainless umbrellas, nylon brushes, and
wards
Ivalon
spongy
bolization
due
stainless
steel
There
was
hepatic
covered
to
bafile
the
umbrellas
created
and
antegrade
thrombosis
ing
a capillary
the and
age of formed the
J. S. was
Patient
II.
the
hemangioma two weeks. a massive
of the
neck
and
of the
right
forehead.
Two
episodes
main
was
very
vascular
and
given,
venous
an
angiogram
with
hemangioma
ear
at
II
tensive to the
I
.
feeders huge
13).
subclavian
of mas-
down
On
a
arterio-
There was congestive heart failure with the liver palpable cm below the right costal margin. The huge heart and pulmonary edema
FIG.
12;
of the
(Fig. II).
shunting
(Fig. right
embolized
to the mass.
output treat
failure.
this in
excluded
It
patient order
by to
additional
Feeders
were embolized
Some
were
as evidenced
branches 23,
feeders
from
the
catheterized
sudden
amputa-
14).
a
1974,
performed,
left
catherized Ivalon plugs
also by
(Fig.
the
and
right
brachial
a No.
cut
French
red
Kifa catheter was introduced selectively into the right thyrocervical trunk which was successfully embolized with Ivalon plugs (Fig. i ; and 16).
Some
of
subclavian
and
the
other
artery
embolized.
feeders
were
The
also
patient’s
from selectively
congestive
the
right
entered
heart
failure did not improve. Because of the potential danger of embolizing the internal cerebral circulation, embolization of the external circulation was carried out by
carotid
from
vascular
angiography reveals cxthe external carotid branches mass.
de-
angi-
from
selectively with
of the
artery
August was
high to
abdomen.
and
1975
supply to the huge mass. 1974, abdominal angiography
trunk
tion
to
(arrors)
embolization
thyrocervical and successfully
and
revealed
little
due
and
the
in
feeders
decided
performed
rapidly
sive external hemorrhage were treated with blood transfusions. A second course of prednisone
be
Ivalon
omas
as hay-
The lesion grew hemangioendothelioma
to
therefore,
was,
was
brushes.
diagnosed
felt
many
crease the vascular On August 19, by
nylon
were
NOVEMBER,
angiogram
reveals
extensive
by fibrin.
artery.
CASE
on
material
K. Amplatz
FIG.
13.
Note disappearance following Ivalon
of major embolization.
feeders
VOL.
125,
No.
Polyvinyl
3
Alcohol
New
Embolic
6i
Material
.
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(Ivalon)-A
“.a
_____
of several feeders which are not named (arrows) from the right subclavian following embolization.
FIG.
14.
obliteration
Note
FIG. 16. Note thyrocervical feeder
surgical artery.
into gram
the
exposure
seen
and
the
and
left
external
vessels
subclavian
occipital
suitable
artery
were
identified
and
At the end of the procedure, to
the
the carotid
mass
left
external
ligated.
The
via
patient
as evidenced by improved alertness.
occipital artery showed
increase
were
(Fig. doses
in food there
thought 17). of
was
The
left
external
from
the
to
selective
right the
be
carotid
left
insignificant
and
catheterization
patient for
not
emboliza-
was
digitalis
ar-
subclavian
discharged
with
congestive
heart
failure.
In spite
intake
or
feeders
for
low
tient
of successful
remained
suggested
the
genital cardiac trocardiographic catherization was corrected
embolization,
in congestive
possibility anomaly and revealed surgically.
heart
the failure
of a complicating
pa-
which
con-
in spite of lacking dccclinical findings. Cardiac a cor
triatriatum
which
A third patient with an arteriovenous malformation of the spinal artery underwent successful Ivalon embolization. This
#{149}
#{149}
#{149} Smany artery
artery
tion
S
FIG. 15. Note thyrocervical
Small
artery, was sur-
no definite decrease in the size of the mass. A follow-up arch aortogram revealed practically no new feeders either from the right
.5
artery
teries.
no flow
improve-
Objectively,
of
cftotid
was selectively introduced carotid artery, and an angioperformed. Large feeding vessels from
was
left
was
ment
the
A catheter the external
embolized.
gically
of
sudden amputation of (arrow) artery and disappearance followi ng embolization.
feeders (arrows) to the huge
from the right vascular mass.
FIG. 17. An arch aortogram tion shows obliteration pare with Fig. II).
after complete embolizaof all major feeders (corn-
S. M.
6i6 case
will
be the
subject
J.
Tadavarthy,
of a separate
H.
report.
Moller
and
sively
used
K. Amplatz in
NOVEMBER,
general
and
1975
cardiac
sur-
9
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DISCUSSION
Angiomatous malformations with arteriovenous shunting are notoriously difficult to correct by surgery. Ligation of the feeding artery results in rapid recurrence due to development of new feeders. In general, only surgical excision of the malformation results in cure which is commonly not possible due to the location of the angiomatous
numerous embolic maclots,’0 silastic emboli, silastic balls, methacrylate,8 stainless steel pellets,4 muscle, etc., have been suggested as embolic material. Ideally the injected emboli should reach the site of the arteriovenous malformation and should not enter into the venous component. With the injection of methacrylate, a liquid polymer, the liquid material may enter the venous side and may become embolized into the pulmonary artery. Barium impregnated silastic balls are attractive. This embolic material is very difficult to handle since it tends to cling to the injection syringe and connecting tubing. Furthermore, since the catheters are very small, such barium balls are minute and difficult to see with the naked eye or roentgenography.
They
may
cause
only
the vessel, whereas in the case oflvalon, the emboli irreversibly result in ultimate complete occlusion. Autogenous clot tends to break up upon injection through small catheters and embolize arteries which are not feeding the
incomplete
occlusion
malformation. of
Tadavarthy, of Radiology of Minnesota
Minneapolis,
Minnesota
We Mary ration
cot
lysis
of
Furthermore, and
major disadvantages Ivalon sponge
recanalization
the
I.
2.
is one
of
Hospitals 5555
wish to give special thanks to Miss Scherman for her help in the prepaof this manuscript.
C. N., and SCHIRE, V. Ivalon baffle for posterior leaflet replacement in treatment of mitral insufficiency: follow-up study. Surgery, 1968, 63, 727-730. BOOKSTEIN, J. J., CHLOSTA, E. M., FOLEY, D., and WALTER, J. F. Transcathether hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology, 1974, 113, 277-
BARNARD,
285.
3.
C., and
B0UTSIS, operation
for
H. Ivalon-sponge-wrap
ELLIS, rectal
26 patients.
prolapse:
Dis.
Colon
with
experience
&
Rectum,
17,
1974,
2 1-37. 4.
J. L., DiCHIRO,
DOPPMAN,
Obliteration formation Lancet, 5. GRINDLAY,
G., and OMMAYA,
A. arteriovenous malembolization.
of spinalcord by percutaneous Zj’J, 477.
1968,
J. H.,
sponge
and
prosthesis
0.
CLAGETT, for
use
after
T.
Plastic
pneumonec-
preliminary report of experimental Proc. Staff Meet. Mayo Ciin., 1949, 24, I 538-I 539. 6. HAWE, A., and RASTELLI, G. C. Late deterioraration of intracardiac Ivalan sponge patches. 7. Thoracic & Cardiovasc. Surg., 1969, 8, 87tomy:
study.
7.
9’. HOGEMAN,
K. E., GUSTAFSON, surgical sponge
G. Ivalon cover
of
experimental
preliminary 121,
8.
possibility
of this technique. seems to be an ideal
M.D.
REFERENCES
malformation.
In recent years terials as autogenous barium impregnated
by
S. Murthy Department University
report.
Ada
G., and BJORLIN, used as temporary skin chir.
defects scandinav.,
in
rats: 1961,
83-89.
A. J., and SPENCE, W. T. Clinical artificial embolization of cerebral arteries. 7.A.M.A., I 960, 172, I I 53-I I 55. PORSTMANN, W., WIERNY, L., WARNKE, H., GERSTBERGER, G., and ROMANIUK, P. A.
LUESSENHOP,
notes:
the
agent for securing permanent hemostasis and promoti ng thrombosis.” The compressed sponge is readily injected and swells upon contact with blood. Incomplete occlusion of small arteries is, therefore, prevented. Once expanded, it is invaded by fibrocytes and becomes part of the patient tissue. Therefore, the material has been exten-
9.
Catheter
closure
Radiol. 10.
Clin.
J.,
RoscH,
Selective for
control
acute
S. M.,
C.,
SNYDER,
transcatheter III,
and arterial
13-16.
and
gastrointestinal 102,
arteriosus.
9, 203-218. BROWN, M. new method bleeding.
1971,
embolization:
I 972,
TADAvARTHY,
1974,
C. T.,
DOTTER,
of
ductus
America,
arterial
Radiology, II.
of patent
North
J.
303-306.
KNIGHT, AMPLATZ,
L., Ovrrr, T. W., K. Therapeutic
embolization.
Radiology,
No.
125,
3
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POLYVINYL
By
S. MURTHY
ALCOHOL EMBOLIC
TADAVARTHY,
M.D.,
(IVALON)-A MATERIAL*
JAMES
H.
MOLLER,
MINNEAPOLIS,
NEW
M.D.,
KURT
and
AMPLA’I’Z,
M.D.
MINNESOTA
ABSTRACT:
Successful nonsurgical treatment of gastrointestinal bleeding and arteriovenous malformations by embolization techniques has been previously documented. i) Compressed Ivalon sponge was found to be a suitable embolic material in animals and in four patients. 2) The material has been extensively used in surgery, and its biocompatibility has been proved. 3) Expansion of the compressed sponge to its original size after embolization makes this material extremely effective. Recanalization did not occur in animals and humans. ) For the occlusion of larger arteries, Ivalon can be wrapped around the guidewire. Ivalon sponge absorbs blood and serum, unwraps itself allowing withdrawal of the guidewire. ) Embolization procedures are not without risk since reflux of embolic material may occur. Therefore, these procedures have to be carried out lJnder fluoroscopic control. T is the purpose of this communication to report the experience with a synthetic embolic material which can be introduced through catheters in the management of gastrointestinal bleeders, arteriovenous malformations, hemangiomas, and traumatic rupture of blood vessels. Ivalon sponge, previously used extensively in surgery, has proved to be a good synthetic embolic material.
is dried and becomes hard, it retains its compressed shape. If placed into an aqueous medium as blood, the compressed sponge resumes its original uncompressed shape as seen in Figure I . The compressed sponge
mm
Ivalon, a polyvinyl alcohol, is converted into a sponge-like material by foaming agents and hardened with formaldehyde. It has been used as an ion exchange resin since this foam is a negatively charged colloid and strongly adsorbs cations. Ivalon is also well known to housewives who use it as a cleaning sponge. Polyvinyl alcohol foam has the ability to absorb water; and it is, therefore, used in industry for electroplating and photography. The material is inert and withstands the action of dilute acids, strong alkalis, and common detergents. Ivalon sponge has the unique property of being resilient and readily compressible when wet. If the compressed *
From
the Department of Radiology, University
work
was
supported
in part
by
USPHS
Grant
T12
HE
length
: .
material
after
being
expanded
to
soaked
in
.
1’
FIG. . figure being
of Minnesota i
Ivalon
in
saline. This excellent plastic memory makes this material particularly attractive for embolization procedures where the size of the embolus is always limited by catheter size.
BACKGROUND
This
long
mm
23
Hospitals, 5853
609
and
Compressed Ivalon expanded six times soaked in saline. Minneapolis,
2
Pol HE
06314.
Minnesota.
at the bottom as seen on the
of top
the after
S. M.
6io
J.
Tadavarthy,
H.
Moller
and
K. Amplatz
NOVEMBER,
5975
mensions
can be reduced by a factor of : I. If dried, the compressed material will retain its shape in spite of gas sterilization. If introduced into the blood stream, it will swell and resume its original shape. Ivalon sponge was soaked in heparin and
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10-15
j,-__
FIG.
2.
Ivalon
ethylene
plugs 240
in pre-loaded
tubes
ready
Clay
Adams
poly-
compressed
for gas sterilization.
in
a vice
and
dried.
One
half
to
mm diameter plugs were cut from the dried material with a hole punch similar to a cork borer or the instrument used to cut side holes on angiographic catheters. These I
PREVIOUS
USES
OF
IVALON
Ivalon sponge has been extensively used in experimental animals as a filling material following pneumonectomy. Autopsy examination revealed that Ivalon sponge is inert and readily invaded by fibrous tissue with a minimal amount of inflammatory cells.5 In 1949 it was first introduced for medical use by J. H. Grindlay5 at the Mayo Clinic. When it was used as a skin graft in experimental animals,7 microscopic examination revealed minimal cellular infiltration. In the 1960’s Ivalon was used as a skin substitute in patients with burns. Because of the pores in the foam, it was permeated with serum and adhered to the skin in one or two days. This material appears to serve as a scaffold for ingrowing connective tissue and becomes an integral part ofthe body. The sponge was also advocated for surgical treatment for rectal prolapse.3 Very recently Porstmann et al,9 used this material for nonsurgical closure of patent ductus arteriosus with excellent results. Polyvinyl alcohol sponge was the synthetic material of choice in the early days of cardiac surgery. The first surgical closure of septal defects in this institution was accomplished by this material; it was used for the reconstruction of the mitral valve in cases of mitral insufficiency, as reported by others.’ Although it was used for the repair of aneurysms, increasing rigidity with time made it necessary to replace it by more pliable and long lasting plastics such as dacron and teflon. However, the biocompatibility of Ivalon sponge has been well established.6 The Preparation of Ivalon Emboli. Ivalon plastic foam is highly compressible in the dry or wet stage. If the material is soaked in
heparin
and
compressed
in a vice,
its
di-
plugs
measured
a
few
mm
in
length
(Fig. Ivalon
pre-loaded in small plastic 2). Depending upon the size plugs, either Clay Adams 240
could
be
were
used
as
pre-loaded
tubes
and
tubing of the or
and
260
gas
sterilized. Care must be taken that only gas sterilization and no steam is used. Otherwise, the compressed plugs will cxpand due to absorption of water and will not be suitable for injection through catheters. At the time of embolization, the pre-loaded tubes are connected to the catheter, and the plugs are flushed into the catheter and blood vessel by forceful manual saline injection. It is very important to eliminate all constrictions between the loading tubes and the selective catheter
FIG.
3.
Selective
renal
Ivalon
angiogram
embolization.
of
a
dog
prior
to
VOL.
since rather these Downloaded from www.ajronline.org by 129.97.124.143 on 02/10/15 from IP address 129.97.124.143. Copyright ARRS. For personal use only; all rights reserved
No.
525,
Polyvinyl
3
the compressed rapidly, making emboli difficult. ANIMAL
The renal with Ivalon. 72
hours
Ivalon prompt
(Ivalon)-A
Ivalon
were was
embolized performed
embolization
of the
clots,
611
and
I,.
‘
#{149} 14 ‘
I.
re-
renal
(Fig.
ofrecanalization
autogenous
Material
EXPERIMENTS
obstruction
evidence
Embolic
plugs swell delivery of
artery with 3 ; and ). Aortography performed one week postembolization revealed occlusion of the renal artery at its most proximal portion due to antegrade thrombosis. The dogs were sacrificed at the end of seven days, and the renal artery and kidneys were subjected to histologic examination. The gross specimen of kidney revealed thrombosis of the main renal artery (Fig. ). Histologic cxamination of the canine renal cortex revealed thrombosis of several renal arteries and noncanalization. The renal cortex showed several areas of hemorrhagic necrosis due to thrombosis of the intrarenal arteries. The problem of lysis and fragmentation which is commonly encountered with no
New
VI
arteries ofdogs Angiography
post
vealed
Alcohol
therefore,
does
not
1 .-.,
#{149}
j 5. The gross specimen reveals thrombosis as by arrow.
of the canine
FIG.
pointed
out
in
renal
artery
this
figure
exist.
This drawback has been well documented by several authors,2”#{176} both in humans and
,
‘#{149} Wm#{149}
I
It is very important to and inject the emboli as close to the lesion as possible. Otherwise, the possibility exists that embolic material may enter other arteries resulting in embolic infarctions. Furthermore, it is cxcanine
selectively
experiments. catheterize
tremely
important
that
the
emboli
are
in-
jected through
slowly, particularly after the flow the artery has decreased. If injection is performed rapidly, embolic material may reflux and embolize other arteries. This has been shown in our laboratory where the renal artery was successfully embolized by Ivalon plugs. At the time of post mortem, however, additional emboli were found in the contralateral renal artery. The gross specimen of the target kidney shows extensive hemorrhagic infarction
FIG. 4. Selective embolization renal
artery
renal reveals (arrow).
angiography complete
72
thrombosis
hours
‘‘V,
due
i
ney post-
of the
to embolization. revealed
The several
contralateral kidareas of infarction catheter was well in
(Fig.
6). Since
the
place
at the
of embolization,
that
the
time
embolization
of the
it is likely contralateral
6i
S. M.
2
f
J.
Tadavarthy,
H.
i..
Moller
and
rapidly
in size
sixteen
months.
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open as
K. Amplatz since of
tion
was
the
At
that
tion
of
a
liver
vealed
a huge
few
injected
emboli
age
oi
an
diagnosed treated
by
February,
1974,
transferred
to the for
as soon
Uni-
considera-
as a donor
be-
angiography
and
vascular
which
of the liver.
hepatic foci
stayed for
was
a candidate
supply-
7). Numerous
(Fig. opacified
evidence
re-
artery for
a
arteriovenous
long
shunt-
ing.
This prior
comparatively
was was
Hospitals
spaces
patient
plantation.
renal artery was due to reflux by a too forceful injection. One of the major advantages of this material is expansion to its original size upon exposure to blood. If the sponge is precompressed io: i, the plug will resume its original proportion after it has been embolized. At the time of embolization, therefore, there is a gradual decrease of flow due to complete obstruction of smaller arteries due to the expansion of the injected Ivalon emboli plugs. This gradual expansion of the embolic material results in a very effective and rapid occlusion of the arterial tree, as evidenced in animal experiments where
in
he was
liver
without
time
out
Abdominal
multiple
vascular due to kidney to force-
which
transplant
available.
ing
was totally infarcted selective embolization. In the contralateral ( arrows), certain areas were infarcted due ful injection of embolic material.
liver
Minnesota
came
the
he had
1973,
involvement
time
of
at
1975
However, his abdomen conin size; and a second explora-
diffuse
versity
kidney
noted
He
carried
revealed
FIG.6.Theright
was
January,
hemangioendothelioma.
radiation therapy. tinued to increase
L.
it
In
biopsy
NOVEMBER,
Decrease to
surgery
Ligation
in
thought
was
of the
hepatic
but due to the artery
was
Therefore,
large size not readily
it
was
for
the
liver
trans-
size
of
the
to
be
essential.
artery
was
liver
proposed;
of the liver, the hepatic accessible by surgery.
decided
to
attempt
trans-
resulted
in complete and rapid thrombosis of the superior mesenteric artery. Ten dogs were subjected to embolization of various arteries. Recently, barium impregnated Ivalon plugs have become commercially available, rendering the embolic material visible by roentgenography. At the present time, our experience is limited to non-opaque Ivalon. Another way to make Ivalon plugs radiopaque would be the incorporation of a stainless steel bead. REPORT CASE
male
I.
with
OF
FIG. 7. Selective hepatic artery
CASES
N. 0. is a four and one-half a liver
tumor
which
year has
old
grown
huge
liver
identified
hepatic angiogram and multiple feeding
mass. without
Numerous arteriovenous
vascular
reveals vessels spaces
shunting.
a large to the were
VOL.
catheter patic
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No.
125,
small
peripheral
hepatic
affected. It was,
hepatic
artery
therefore,
strainless
steel
branches,
would
have
decided
umbrella
to
which
613
cutdown
of
hepatic
artery
three
stainless
through
the
as
left
steel
the
catheter.
through
the
small
nylon
bristle
brushes
catheter
using
Ivalon seemed
to
brushes
and the
the
metal
of
flow through as evidenced
the
patient
tion
with
The and
were
placed
small
emboli
umbrellas, were
two
delivered
(Fig.
umbrella.
procedure
there
to showed rise
of
At was
the embolized by angiography.
material t throm
acted bus
the
the
and nylon
embolization to
______J
nidus
units,
funcwhich
ultimately returned to #{231}o units, his bilirubin rose as high as mgm but declined to 2.3 mgm. Shrinkage of the liver by approximately cm above the pubis was noted, but he developed more ascites and his abdominal girth
umbrella
did A
not change. follow-up
angiogram
vealed
complete
occlusion
at
its
origin
to the liver the aorta
(Fig.
9).
at the site
of the flow to branches
The collateral
pooling
of
he was had
a blood
and
received
massive in
to
became
of less
be
right
and
store At
glycogen. autopsy
the
a
tumor
replaced
tumor
was
to hepatic
soft arterial
It
that large
the
and
to
of was
nodular
necrotic embolization.
to
percent
glucose.
his
liver
the
found
was
A
field
felt
of
his
entire
was
lung
because
fact
di-
lethargic
io mgm
upper
metastatic.
hypoglycemic
intake
He
than
infusions
the
dem-
markedly
admission
arrest.
sugar
found
last
directly arteries
to be extremely
a respiratory
have
collateral
previously
was
his
noted
artery
of
in the
re-
1974,
hepatic arising phrenic
spaces
morning
hospital,
April,
branches inferior
vascular
minished. On the
in
of the
demonstration via and
Venous
onstrated
thought
constructed the stainless
with
flow from
nodule
FIG. 8. Guidewire (A) with specially blunt knob that was used to advance umbrella (B) and nylon brush (C).
artery
(arrow).
from
and
C
of hepatic
the liver was maintained via unnamed the aorta and inferior phrenic arteries.
no ar-
procedure, of liver
720
stainless
practically hepatic Obviously
9. Thrombosis
FIG.
comple-
as an excellent formation.
deterioration SGOT
via
8).
emboli were then delivered pile up at the site of the
blood tery
subsequen Subsequent
the
steel
a guidewire
tion
foreign
artery.
catheterized,
Since
pass
ad-
was inserted
umbrellas
could
a be
the catheter, enibolic ma-
brachial
selectively
un-
construct
with the guidewire through serving as a baffle for the injected terial (Fig. 8). The No. 7 French teflon catheter
for
Material
but
been
could
vanced
the
Embolic
was
main
via
New
embolization. Since the hehuge, injection of small emboli not be used in this case. The injection of emboli would have resulted in obstruction
of a few
the
(Ivalon)-A
Alcohol
arterial
artery
could small
Polyvinyl
3
was
that
he
poor
oral
unable
to
reddish-brown
liver.
A
possibly The
portion
of
secondary final
diag-
nosis was hemangiosarcoma of the liver with rnetastases to the lungs. Pathological examination of the common hepatic artery shows the stainless umbrellas, nylon brushes, and the spongy material, namely polyvinyl alcohol (Ivalon) (Fig. io). There was no distal em-
S. M.
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614
J.
Tadavarthy,
H.
Moller
FIG.
and
Selective
I 2.
artery FIG. 10. artery
Postmortem examination of the hepatic reveals thrombosis. The arrows point tothe stainless umbrellas, nylon brushes, and
wards
Ivalon
spongy
bolization
due
stainless
steel
There
was
hepatic
covered
to
bafile
the
umbrellas
created
and
antegrade
thrombosis
ing
a capillary
the and
age of formed the
J. S. was
Patient
II.
the
hemangioma two weeks. a massive
of the
neck
and
of the
right
forehead.
Two
episodes
main
was
very
vascular
and
given,
venous
an
angiogram
with
hemangioma
ear
at
II
tensive to the
I
.
feeders huge
13).
subclavian
of mas-
down
On
a
arterio-
There was congestive heart failure with the liver palpable cm below the right costal margin. The huge heart and pulmonary edema
FIG.
12;
of the
(Fig. II).
shunting
(Fig. right
embolized
to the mass.
output treat
failure.
this in
excluded
It
patient order
by to
additional
Feeders
were embolized
Some
were
as evidenced
branches 23,
feeders
from
the
catheterized
sudden
amputa-
14).
a
1974,
performed,
left
catherized Ivalon plugs
also by
(Fig.
the
and
right
brachial
a No.
cut
French
red
Kifa catheter was introduced selectively into the right thyrocervical trunk which was successfully embolized with Ivalon plugs (Fig. i ; and 16).
Some
of
subclavian
and
the
other
artery
embolized.
feeders
were
The
also
patient’s
from selectively
congestive
the
right
entered
heart
failure did not improve. Because of the potential danger of embolizing the internal cerebral circulation, embolization of the external circulation was carried out by
carotid
from
vascular
angiography reveals cxthe external carotid branches mass.
de-
angi-
from
selectively with
of the
artery
August was
high to
abdomen.
and
1975
supply to the huge mass. 1974, abdominal angiography
trunk
tion
to
(arrors)
embolization
thyrocervical and successfully
and
revealed
little
due
and
the
in
feeders
decided
performed
rapidly
sive external hemorrhage were treated with blood transfusions. A second course of prednisone
be
Ivalon
omas
as hay-
The lesion grew hemangioendothelioma
to
therefore,
was,
was
brushes.
diagnosed
felt
many
crease the vascular On August 19, by
nylon
were
NOVEMBER,
angiogram
reveals
extensive
by fibrin.
artery.
CASE
on
material
K. Amplatz
FIG.
13.
Note disappearance following Ivalon
of major embolization.
feeders
VOL.
125,
No.
Polyvinyl
3
Alcohol
New
Embolic
6i
Material
.
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(Ivalon)-A
“.a
_____
of several feeders which are not named (arrows) from the right subclavian following embolization.
FIG.
14.
obliteration
Note
FIG. 16. Note thyrocervical feeder
surgical artery.
into gram
the
exposure
seen
and
the
and
left
external
vessels
subclavian
occipital
suitable
artery
were
identified
and
At the end of the procedure, to
the
the carotid
mass
left
external
ligated.
The
via
patient
as evidenced by improved alertness.
occipital artery showed
increase
were
(Fig. doses
in food there
thought 17). of
was
The
left
external
from
the
to
selective
right the
be
carotid
left
insignificant
and
catheterization
patient for
not
emboliza-
was
digitalis
ar-
subclavian
discharged
with
congestive
heart
failure.
In spite
intake
or
feeders
for
low
tient
of successful
remained
suggested
the
genital cardiac trocardiographic catherization was corrected
embolization,
in congestive
possibility anomaly and revealed surgically.
heart
the failure
of a complicating
pa-
which
con-
in spite of lacking dccclinical findings. Cardiac a cor
triatriatum
which
A third patient with an arteriovenous malformation of the spinal artery underwent successful Ivalon embolization. This
#{149}
#{149}
#{149} Smany artery
artery
tion
S
FIG. 15. Note thyrocervical
Small
artery, was sur-
no definite decrease in the size of the mass. A follow-up arch aortogram revealed practically no new feeders either from the right
.5
artery
teries.
no flow
improve-
Objectively,
of
cftotid
was selectively introduced carotid artery, and an angioperformed. Large feeding vessels from
was
left
was
ment
the
A catheter the external
embolized.
gically
of
sudden amputation of (arrow) artery and disappearance followi ng embolization.
feeders (arrows) to the huge
from the right vascular mass.
FIG. 17. An arch aortogram tion shows obliteration pare with Fig. II).
after complete embolizaof all major feeders (corn-
S. M.
6i6 case
will
be the
subject
J.
Tadavarthy,
of a separate
H.
report.
Moller
and
sively
used
K. Amplatz in
NOVEMBER,
general
and
1975
cardiac
sur-
9
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DISCUSSION
Angiomatous malformations with arteriovenous shunting are notoriously difficult to correct by surgery. Ligation of the feeding artery results in rapid recurrence due to development of new feeders. In general, only surgical excision of the malformation results in cure which is commonly not possible due to the location of the angiomatous
numerous embolic maclots,’0 silastic emboli, silastic balls, methacrylate,8 stainless steel pellets,4 muscle, etc., have been suggested as embolic material. Ideally the injected emboli should reach the site of the arteriovenous malformation and should not enter into the venous component. With the injection of methacrylate, a liquid polymer, the liquid material may enter the venous side and may become embolized into the pulmonary artery. Barium impregnated silastic balls are attractive. This embolic material is very difficult to handle since it tends to cling to the injection syringe and connecting tubing. Furthermore, since the catheters are very small, such barium balls are minute and difficult to see with the naked eye or roentgenography.
They
may
cause
only
the vessel, whereas in the case oflvalon, the emboli irreversibly result in ultimate complete occlusion. Autogenous clot tends to break up upon injection through small catheters and embolize arteries which are not feeding the
incomplete
occlusion
malformation. of
Tadavarthy, of Radiology of Minnesota
Minneapolis,
Minnesota
We Mary ration
cot
lysis
of
Furthermore, and
major disadvantages Ivalon sponge
recanalization
the
I.
2.
is one
of
Hospitals 5555
wish to give special thanks to Miss Scherman for her help in the prepaof this manuscript.
C. N., and SCHIRE, V. Ivalon baffle for posterior leaflet replacement in treatment of mitral insufficiency: follow-up study. Surgery, 1968, 63, 727-730. BOOKSTEIN, J. J., CHLOSTA, E. M., FOLEY, D., and WALTER, J. F. Transcathether hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology, 1974, 113, 277-
BARNARD,
285.
3.
C., and
B0UTSIS, operation
for
H. Ivalon-sponge-wrap
ELLIS, rectal
26 patients.
prolapse:
Dis.
Colon
with
experience
&
Rectum,
17,
1974,
2 1-37. 4.
J. L., DiCHIRO,
DOPPMAN,
Obliteration formation Lancet, 5. GRINDLAY,
G., and OMMAYA,
A. arteriovenous malembolization.
of spinalcord by percutaneous Zj’J, 477.
1968,
J. H.,
sponge
and
prosthesis
0.
CLAGETT, for
use
after
T.
Plastic
pneumonec-
preliminary report of experimental Proc. Staff Meet. Mayo Ciin., 1949, 24, I 538-I 539. 6. HAWE, A., and RASTELLI, G. C. Late deterioraration of intracardiac Ivalan sponge patches. 7. Thoracic & Cardiovasc. Surg., 1969, 8, 87tomy:
study.
7.
9’. HOGEMAN,
K. E., GUSTAFSON, surgical sponge
G. Ivalon cover
of
experimental
preliminary 121,
8.
possibility
of this technique. seems to be an ideal
M.D.
REFERENCES
malformation.
In recent years terials as autogenous barium impregnated
by
S. Murthy Department University
report.
Ada
G., and BJORLIN, used as temporary skin chir.
defects scandinav.,
in
rats: 1961,
83-89.
A. J., and SPENCE, W. T. Clinical artificial embolization of cerebral arteries. 7.A.M.A., I 960, 172, I I 53-I I 55. PORSTMANN, W., WIERNY, L., WARNKE, H., GERSTBERGER, G., and ROMANIUK, P. A.
LUESSENHOP,
notes:
the
agent for securing permanent hemostasis and promoti ng thrombosis.” The compressed sponge is readily injected and swells upon contact with blood. Incomplete occlusion of small arteries is, therefore, prevented. Once expanded, it is invaded by fibrocytes and becomes part of the patient tissue. Therefore, the material has been exten-
9.
Catheter
closure
Radiol. 10.
Clin.
J.,
RoscH,
Selective for
control
acute
S. M.,
C.,
SNYDER,
transcatheter III,
and arterial
13-16.
and
gastrointestinal 102,
arteriosus.
9, 203-218. BROWN, M. new method bleeding.
1971,
embolization:
I 972,
TADAvARTHY,
1974,
C. T.,
DOTTER,
of
ductus
America,
arterial
Radiology, II.
of patent
North
J.
303-306.
KNIGHT, AMPLATZ,
L., Ovrrr, T. W., K. Therapeutic
embolization.
Radiology,
