The appropriate choice
Case 55
【Embolization】
First, a microcatheter using a microguidewire was advanced selectively to A3 and coil embolization using a straight-type microcoil was conducted. Then, a microcatheter was advanced selectively to A2 and coil embolization using a tornado-type microcoil was done. However, left hepatic arteriography showed still marked extravasation of contrast medium (Fig. 5). Embolization of left hepatic artery itself was added using a few microcoils (tornado-type). After embolization, angiography showed complete occlusion of left hepatic artery with disappearance of extravasation of contrast medium (Fig. 6).
【Progress】
Immediately after embulization,She escaped from the condition of sub-shock. The following day, non-enhanced CT showed marked decrease of hematoma in the intraperitoneal space and hepatic subcapsular area, although plural hematoma or plural effusion remained (Fig. 7). She was given intravenous infusion of antibiotics for sepsis. Approximately one month later, she discharged with a healthy condition.
【Discussion】
As a treatment strategy, when arterial hemorrhage occurred in the peripheral site where a microcatheter cannot be inserted, embolization with gelatin sponge particles or n-butylcyanoacrylate (NBCA) is conducted. In case of coagulopathy, embolization with NBCA is more preferable than that with gelatin sponge particles (1) as described in Case 54. Meanwhile, when a microcatheter can be advanced to the arterial hemorrhage site, microcol embolization can be done irrespective of coagulopathy. Microcoil embolization is available for arterial hemorrhage from medium-sized artery using an isolation technique. An isolation technique was termed since the bleeding point was isolated by placing microcoils from the distal side to the proximal side beyond the bleeding site. In our case, we occluded A2 and A3 with placing microcoils from distal branch to proximal side, inducing complete occlusion.
A 4F catheter system was necessary for microcoil embolization a few years ago. However, thanks to technical advance, the lumen of the 3F catheter is expanded. Some microcatheters which allow microcoil embolization become to be able to pass through the lumen of 3F catheter. However, other microcatheters aiming the super-catheterization still do not so wide lumen as to allow microcoil embolization. Therefore, when you use a 3F catheter system with aiming coil embolization, the appropriate choice of microcatheter in advance is crucial as a therapeutic method. In our case, a 3F RC2 catheter and a microcatheter (Parkway C3) which allows microcoil embolization, were adopted.
As microcoils for ceasing arterial bleeding, straight coils, tornado coils and detachable coils are listed (Figs 8-10). Straight coils and tornado coils own silk fiber attached to the metal in order to prompt formation of red thrombus (Figs 8, 9) (1, 2, 3). Straight coils are used for thin arteries and tornado coils have variable sizes for medium sized arteries. Meanwhile, although detachable coils do not own silk fiber (Fig. 10), they are available for occlusion of large and/or long-distance artery (4) or for embedding aneurysm. In our case, a straight coil was first used for occlusion of branch artery of A3, but angiography revealed insufficient occlusion. Then, several tornado coils are used for occlusion of left hepatic artery.
【Summary】
We present a patient with sepsis and acute hemorrhage from left hepatic artery caused by repeated needle puncture for liver abscess drainage. Microcoil embolization in made a to successful hemostasis and transient drainage and antibiotics cured sepsis and liver abscess, leading to discharge in the healthy condition. We should keep in mind that acute hemorrhage from medium-sized artery can be treated by microcoil embolization.
【References】
1.Yonemitsu T, et al. : Evaluation of transcatheter arterial embolization with gelatin sponge particles, microcoils, and n-butyl cyanoacrylate for acute arterial bleeding in a coagulopathic condition. J Vasc Interv Radiol 20: 1176-1187, 2009
2.d'Othée BJ, et al. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol. 2006 Jan-Feb;29:49-58.
3.Kuo WT, et al. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2003 Dec;14:1503-9.
4.Takasaka I, et al. Preoperative microcoil embolization of the common hepatic artery for pancreatic body cancer. World J Gastroenterol 18: 1940-1945, 2012
2017.5.24