embolization

Embolization

Cutting off blood supply therapeutically

Cutting off blood supply to a specific area of the body can be an important form of care when treating tumors (or other abnormal growths), internal bleeding, defects in blood vessels, or other conditions. Interventional radiologists can inject special materials that form a blockage (embolize) arteries and other areas to close off (occlude) them for this purpose.

Embolization reduces or blocks blood flow to abnormal areas or locations of blood loss or pooling.

In these embolization procedures, the interventional team will first create an image of the distorted veins using various forms of angiography . Then the specialists will introduce a catheter (small plastic tube) into a primary artery and advance it to the area to which there is a need to cut off blood supply. The specialists inject a granulized or particulate material that congeals and hardens, thus blocking blood flow. Or, they may insert a metallic coil through the catheter that remains in place so that the body will form a blood clot around the coil and block off the area. The materials used may depend on the size and type of area to be closed and on whether the occlusion is intended to be temporary or permanent.

This transcatheter embolization has a variety of applications, including most importantly:

• fibroid masses. One use of the technique that has received significant attention recently is in uterine artery embolization , where the purpose is to kill or shrink fibroid masses in the uterus. The treatment addresses pelvic pain, excessive bleeding, and other symptoms of abnormalities in the uterus.

• aneurysms. Specialists also use embolization to block aneurysms (areas in arteries that are weakened and bulging) in different locations of the body. The treatment seeks to seal off the aneurytic bulge, as well as the neck of the bulge within the artery. Interventionalists can permanently deploy a tiny coil of soft-metal filament in the aneurysm, providing a much-preferable alternative to surgery to remove the aneurysm. This the procedure has allowed treatment of aneurysms that were previously considered in operable. The procedure reduces much of the danger presented by aneurysms and can sometimes be used to treat aneurysms that have already ruptured. (Note that in recent years, in the hands of neurosurgeons - or at some centers, interventional neuroradiologists - endovascular coil embolization has become a standard treatment for patients who have a brain aneurysm but who are at high risk for complications from a surgical repair of the aneurysm.)

Varicocele Treatment

Varicocele is a common condition among males, most likely to occur in the teens and twenties. In this condition, the tiny veins through which blood flows out of the testicles fail to withstand the reverse forces of blood flow from gravity and pressure, and they become enlarged and misshapen. While they may or may not be visible, these tangled vessels become, effectively, varicose veins within the scrotum.

In some men, they may go unnoticed, but in others they cause symptoms that can include pain and shrinkage of the testicles. Varicocele is a primary cause of male fertility problems. If a varicocele is not visible the radiologist may diagnose it using ultrasound or venography.

Interventional radiologists can provide the most up-to-date solution available for varicocele. By embolizing the abnormal veins present in this condition, they deliver a painless solution that causes the problem veins to wither, the scrotum to return to normal, and the symptoms to resolve. The treatment is nearly identical to interventional treatment for varicose veins. After the procedure, blood detours through other veins that are normal, and the treated veins are gradually reabsorbed by the body. The treatment is highly effective in resolving the symptoms of varicocele.

Partly because awareness of this option is still growing, many men continue to undergo conventional surgery for varicocele. The surgeon must make an incision in the scrotum and tie off the abnormal veins. Patients need weeks to recover from this operation.

But with varicocele embolization there are no stitches (and no incision in the scrotum), and patients usually go home the same day. In addition, they typically return to normal activities within 48 hours.

• tumors. The technique can also be used to reduce or destroy cancerous tumors. For tumor control, embolization is a more likely approach if the tumor is difficult to remove surgically, due to its location. This is particularly relevant for liver tumors or for certain tumors with extensive blood supply such as those resulting from kidney cancer. The cancer team will sometimes use the step to reduce tumors prior to, and make them more amenable to, surgery.

In a tumor embolization procedure, the cancer team can also deliver chemotherapeutic drugs through the catheter to more directly expose the tumor to these cancer-killing agents, and decrease the amount of drug circulated systemwide in the body. This treatment is called chemoembolization . Tumor embolization can be a highly effective step for control of pain resulting from tumor growth, and can help some patients avoid powerful, opiate pain-killing drugs.

• arteriovenous malformations (AVMs). Included among vascular problems treated with embolization are arteriovenous malformations (AVMs), an unusual condition in which an artery and vein have an abnormal connection, causing leaking and mixing of blood between arterial and venous supplies

• bleeding. Embolization is an important option in treating internal bleeding and is used for this application more often than for any other purpose. Radiologists employ the approach to stop or reduce gastrointestinal bleeding in cases where ulcers bleed into the stomach or intestines, and for blood-vessel ruptures in or around the digestive tract (mesenteric bleeding). The radiologic specialists also use embolization commonly interventional treatments for trauma , where frequently the technique is essential to stop bleeding into the abdomen or pelvis in individuals who have been injured in automobile accidents. Finally, the IR team may also apply the treatment to stop severe postpartum bleeding and even to stop severe nose bleeds.

• enlargement. Splenic embolization is a newer technique developed as an alternative to splenectomy (open surgical removal of all or part of the spleen). Splenic embolization is designed primarily for patients who are unlikely to tolerate an open surgical procedure well but who suffer from enlarged spleens. This type of embolization involves introducing a catheter and advancing it to the splenic artery to partially plug or block this artery that supplies blood to the spleen. The step shrinks the spleen. Substances injected during this procedure to create the blockage can include polyvinyl alcohol foam, polystyrene, or silicone.

For an embolization procedure, the IR team will typically sedate the patient and insert the catheter into the femoral artery or vein, through a small incision in the groin (although vessels in the arm or neck may also be used). With the imaging guidance, they painlessly advance the catheter to the site of the vein or artery that needs to be closed off.

Depending on the problem and the objective of the embolization, the team may inject gelfoams, glues, or scarring agents (sclerosant), as alternatives to particles or coils, as the embolizing agent. Also, the specialists will sometimes need to repeat the embolization procedure at intervals to fully plug vessels. (For malformations that consist simply of an abnormal cluster of blood vessels or lymph material, the specialists can sometimes inject a scarring agent with a needle placed through the skin, to clot and shrink the malformation, in a treatment called sclerotherapy.)

Embolization is an effective intervention for stopping blood flow to targeted areas. It results in minimal blood loss, and allows most patients to avoid general anesthesia. In addition, unless their condition has caused bleeding, patients who undergo embolization generally have a short hospital stay of approximately one night and will resume normal activities within a week. A few weeks or months may be needed to fully determine whether the embolization has achieved its aim of controlling symptoms (including pain and other tumor-related complications), bleeding, or growths.

The IR team will usually follow up the procedure with additional angiography or other imaging to evaluate the positioning and results of the embolization. The success rates of embolization are high, and the procedure is dramatically less invasive than open surgery, making recovery much quicker and easier.

Pelvic Congestive Syndrome

Pelvic congestive syndrome is a diagnostic term and a condition that has received renewed attention in recent years, as understanding of the phenomenon, and ability to diagnose it accurately and treat it properly, have improved. The syndrome is thought to cause chronic pelvic pain as a result of varicosing of veins that drain blood from the ovaries. (Indeed, pelvic congestive syndrome occurs more often in women who have varicose veins of the legs as well. Pregnancy, ovarian cysts, and hormonal dysfunction may also be risk factors for this condition.) The valves that prevent the reverse flow of blood in the venous system are defective in such veins. For this reason, blood pools in these vessels. The result is swollen, distorted, misshapen veins that, in the pelvis, cause pressure and pain due to their enlargement. In the course of a day, the resulting discomfort can be get worse, the longer women with the condition remain in the upright position.

The ovarian veins are susceptible to such expansion and congestion as a result of their anatomy and their relatively unsupported position along the pelvic sidewall. Varicose veins in the pelvis are a common condition, though they do not always cause symptoms. Recent data, however, indicates that pelvic congestive syndrome may be a very common cause of chronic pelvic pain.

Thus, pelvic congestive syndrome is increasingly recognized as a potential basis of otherwise unexplained, long-term pelvic pain in women. Many specialists consider it significantly underdiagnosed and undertreated. The condition has been associated with other symptoms such as menstrual irregularities; sexual problems; abdominal distension; irritable bladder; varicose veins in the vulva, buttocks, or thigh; and sometimes serious discomfort before, during, and after menstruation.

Varicosities of one or more of the ovarian veins may be difficult to detect. If other conditions are ruled out, our staff may order a venogram (performed in a partly vertical position), to create an image of the vessels that may be varicosed. Gynecologic surgeons may also diagnose the syndrome by conducting a special type of laparoscopy using only local anesthesia and minimal sedation, in which they touch different pelvic structures with a probe to identify the source of the patient's pain.

Drug treatment can be effective, using over-the-counter analgesics or prescription anti-inflammatories, or through hormonal suppression including with birth control pills. Other options include surgical ligation of the vein, or surgical removal of the uterus and ovaries. (Hysterectomy alone is not considered effective.) In a newer approach, though, Aria's interventional radiologists can also embolize these veins. This treatment plugs the blood vessels, causing them to shrink and disappear. This approach spares women from having to undergo surgery, is effective in reducing pain, and preserves ovarian function.