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David Kessel and Charles Ray - Transcatheter Embolization and Therapy

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David Kessel and Charles Ray Transcatheter Embolization and Therapy

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David Kessel and Charles Ray - Transcatheter Embolization and Therapy
Transcatheter Embolization and Therapy
David Kessel and Charles Ray
Transcatheter Embolization and Therapy

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Part 1
Section I
David Kessel and Charles Ray (eds.) Techniques in Interventional Radiology Transcatheter Embolization and Therapy 10.1007/978-1-84800-897-7_1 Springer-Verlag London Limited 2010
1. Basic Principles of Embolization
Iain Robertson 1
(1)
Department of Imaging, Gartnavel General Hospital, Glasgow, UK
Abstract
Embolization therapy covers an enormous spectrum of procedures, from simple varicocoele embolization to occlusion of complex arteriovenous malformations. Both procedures aim to provide vascular occlusion, but the techniques, equipment, approach, outcomes, and hazards are very different. This chapter aims to set the scene for the rest of the book by covering some of the philosophy of embolotherapy. Later chapters in this section will deal with specifics of embolic agents and imaging. The second section covers individual indications.
Introduction
Embolization therapy covers an enormous spectrum of procedures, from simple varicocoele embolization to occlusion of complex arteriovenous malformations. Both procedures aim to provide vascular occlusion, but the techniques, equipment, approach, outcomes, and hazards are very different. This chapter aims to set the scene for the rest of the book by covering some of the philosophy of embolotherapy. Later chapters in this section will deal with specifics of embolic agents and imaging. The second section covers individual indications.
Underlying Principles
There is no one size fits all solution to embolization, and success is dependent on adapting the procedure to account for the unique problems presented by each patient. Embolization is often technically demanding and mistakes can have serious consequences. It is often impossible to recanalize a vessel or vascular bed accidentally occluded during treatment.
The aim of every embolization treatment is to deliver effective treatment while minimizing damage to adjacent structures. This will only occur with careful planning and execution . The remainder of this chapter will cover concepts which can be applied across the entire range of embolotherapy.
Knowledge : Before starting any embolization procedure, it is essential to have a thorough understanding of the following:
  • The pathophysiology of the underlying condition
  • The role of alternative therapies
  • The likely therapeutic outcomes of the various therapies
  • The vascular anatomy relevant to the clinical scenario
  • The different types of embolic agents and how to use them
  • The likelihood of success and recurrence
  • The potential to cause and manage adverse events
    • target organ dysfunction
    • collateral (non-target) embolization
    • post-embolization syndrome
Planning the Procedure
Planning, understanding, good technique, and a high level of vigilance can avoid many of the complications associated with embolization. Careful planning should start well in advance of the procedure and has been made easier by the advent of computed tomography (CT) and magnetic resonance (MR) angiography. The key elements in planning are as follows:
Understanding the Underlying Pathological Process
The conditions treated by embolization have very different pathophysiological driving processes and have different treatment objectives, and therefore require different treatment strategies. Broadly speaking
  • If the pathology has an ongoing tissue-based process (e.g., inflammatory/ neoplastic), then occlusion is required at small vessel/capillary level to achieve a durable result.
  • When there is a single stimulus to vessel injury (e.g., post-renal biopsy), then occlusion at arterial level will be enough to produce a durable result, though reperfusion via collateral pathways needs to be considered.
Understanding the Role of Alternative Therapies
Embolotherapy may be the only one of several therapeutic options for a particular scenario. It is important to understand the pros and cons of all of the alternative therapies and for these to be discussed with the referring clinicians and the patient. As always, there are a range of possibilities as follows:
  • Embolization may be complementary to other therapies.
  • Embolization may be a vital prelude to other therapy (e.g., surgery).
  • Embolization may be the only viable therapy.
  • Embolization may not be the optimal therapy.
Which of these is true will depend on the circumstances of the case and the local expertise. Be flexible, honest, and pragmatic.
Identifying the Target
Clearly it is impossible to treat anything unless you know the location, the local blood supply, and any other tissues that may be affected by vascular occlusion.
  • Often common sense will direct you to the appropriate vascular distribution. In the example above, bleeding following renal biopsy will originate from the corresponding renal arterial branches.
  • When the situation is not so obvious (e.g., gastrointestinal hemorrhage), then cross-sectional imaging will commonly identify the site of bleeding. This will often direct angiographic interrogation.
  • Most proximal arterial variations can be identified by careful interpretation of CT angiography.
  • CT will not always identify the vessel of origin. For example, bleeding into the retroperitoneum can come from a large number of adjacent vesselsand some work will still be required at angiography!
Knowing the Arterial Anatomy and Collateral Pathways
Understanding the arterial and venous anatomy of the target lesion is essential to permit safe and effective embolization. Embolization requires both meticulous angiographic technique and patience to carefully unravel the pathway to the target lesion.
Normal Anatomy and Anatomic Variations
Arterial and venous variants are a common trap for the unwary, and knowledge of the common patterns can prevent an easy case going far astray.
  • In general, even with the advent of CT and MR angiography, it is always better to start by establishing the arterial anatomy with overview (non-selective) angiography.
  • In some vascular territories (e.g., the visceral circulation), variant anatomy will be present in over a quarter of cases. Subtle arterial variations are still best appreciated at selective angiography. Only after the anatomy has been established should the operator proceed to more selective catheterization of the target vessel.
Collateral Perfusion
  • Collateral pathways are a mixed blessing for embolization therapy. While in some circumstances the existence of a collateral pathway can prevent tissue ischemia after embolization, the same network of pathways may continue to perfuse a target lesion beyond embolization coils.
  • The classic collateral pathway of the gastroduodenal artery (Fig.) is a perfect illustration. A lesion in the mid gastroduodenal artery cannot be successfully treated by proximal embolization of the common hepatic artery or even the gastroduodenal artery alone. The lesion will continue to be supplied via the superior mesenteric artery/inferior pancreaticoduodenal arcade.
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