Embolization

I Implantation of a Port

Pectoral Muscle Port

Fig. 7.14 The port reservoir with inserted port needle is located on the pectoral muscle and the tip of the port tube is visualized in the cava at the correct level, that is, just superior to the right atrium.

Checklist:

Embolization

• Is the region to be embolized dependent on an end artery?

• Does the vascular territory to be embolized feed other crucial vessels?

• Is there a danger of preexistent collaterals into vulnerable regions opening during the embolization?

Fig. 7.14 The port reservoir with inserted port needle is located on the pectoral muscle and the tip of the port tube is visualized in the cava at the correct level, that is, just superior to the right atrium.

mage to the lid using dedicated special tip needles (port needles). Foxhenry tunnels the skin from the pocket to the puncture site with a flexible blunt rod and pulls the port tube through. "Now check this out," he grins to Giu-feng. "How do we get rid of the sheath?" Giufeng gives him a helpless glance. "We call this the 'banana-peel-technique.' You pull the sheath out of the vessel, then grab those two lashes at its end and pull them apart. The sheath is split in two halves and the port tube is freed. Cunning, isn't it?" The tube is cut to the correct length, tube and reservoir are connected, and both skin openings are sutured. Foxhenry tests the function of the port using that dedicated port needle and a little contrast and is quite satisfied with the end result (Fig. 7.14).

A vascular port may only be punctured with a so-called port needle. Normal needles cause leaks! After use, the port must be filled with heparinized saline to prevent clotting of the port tube.

This Vascular Bed is Put to Rest!

Sid McFlennan (64) had his left kidney removed six months ago because of a renal cell carcinoma. Now he has developed a large swelling in the right thigh after an awkward movement. The radiograph has shown a pathological femur fracture just below the tro-chanter (Fig. 7.15a). The trauma surgeons want to stabilize the fracture but they fear the large hypervascu-larized metastatic mass in the area. For that reason they have asked for the preoperative embolization of the mass. Dr. Chaban looks at the images together with Paul and Ajay.

^ Procedure: Chaban punctures the femoral artery in the groin in antegrade direction and performs an angiogram of the vascular territory in question (Fig. 7.15b). The large hy-pervascularized mass lights up with contrast right away— the trauma surgeon's call for help seems justified. Over a selective catheter Chaban injects tissue glue into the feeding vessels and puts some endovascular coils on top (Fig. 7.15c). "Now it is the surgeon's game," he nods to Paul. Ajay wonders where else the technique can be used. "Embolizations of this kind can be performed in all kinds of tumor bleeds. You can, for example, also treat uterine leiomyomas like that. Angiomas and arteriovenous malformations [Fig. 7.16a, see also p. 249] are also dealt with in that fashion. But the action can become extremely tricky if you work in vital vascular territories like, for example, the spinal cord. Obstruction of important vessels with dislodged embolic material or by iatrogenic dissections is the most relevant and consequential complication," Chaban says with an earnest look on his face. "Fascinating," says Ajay. Paul is impressed. He has seen enough—intervention is just not his cup of tea.

Embolizations had better be done by cold-blooded pros.

I Embolization of a Metastasis

I Embolization of a Metastasis

Embolization Foot
Fig. 7.15 a This metastasis has destroyed the cancellous bone and eroded the cortex. The fragments are scattered around in the adjacent tissue. b Selective angiography of the femoral ar

tery shows the tumor's vascular bed supplied by branches arising from the deep femoral artery. c The final run after embolization shows only little residual vascularization within the tumor.

I Embolization of Arteriovenous Malformations

Embolization Foot

Fig. 7.16a This young man has a vascular malformation of the foot that is the cause of increasing problems: for a start, his shoes do not fit anymore. After percutaneous puncture of the vascular mass with a butterfly needle, the whole extent of the lesion is visualized angiographically. b Subsequently, tissue glue mixed with contrast is injected under fluoroscopy. The mass will shrink in the weeks and months to come and with a little luck the symptoms will dwindle. c The arteriovenous malformation depicted in this pulmonary angiogram caused relevant shunting. d The obstruction of the feeding vessel with a few coils settled the problem.

Fig. 7.16a This young man has a vascular malformation of the foot that is the cause of increasing problems: for a start, his shoes do not fit anymore. After percutaneous puncture of the vascular mass with a butterfly needle, the whole extent of the lesion is visualized angiographically. b Subsequently, tissue glue mixed with contrast is injected under fluoroscopy. The mass will shrink in the weeks and months to come and with a little luck the symptoms will dwindle. c The arteriovenous malformation depicted in this pulmonary angiogram caused relevant shunting. d The obstruction of the feeding vessel with a few coils settled the problem.

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