1. Z.ATANASOV, I.MILEV, S.IDRIZI, V.AMPOVA-SOKOLOV, Z.ZIMBAKOV, T.ANGJUSEVA, E.IDOSKI, Z.MITREV

2. Introduction Transcatheter embolization is a therapeutic instilation of various substances into the circulation to occlude vessels, either to terminate or prevent hemorrhage, to devitalize a tumor or organ, or to reduce blood flow to an arteriovenous malformation (Stedman, 2000).

3. Goals 1. Definitive treatment (bleeding, AVFs, AVMs, aneurysms) 2. Adjunctive: preoperative, chemotherapy or radiation therapy 3. Paliative: large AVMs which cannot be cured by embolization

4. Medical conditions Hemorrhage: - bleeding, - aneurysm, - pseudoaneurysm LGIB – low gastrointestinal bleeding (in 85% of cases involves colon) (in 85% of cases involves colon)

5. Medical conditions Vascular anomalies: - AVM - AVF - venous malformation - haemangioma AVM of the coecum

6. Medical conditions Other conditions: - tumor - organ ablation - varicocoela

7. Embolization materials and substances (liquid, solid) 1.Coils: macrocoils (4F, 5F) microcoils (2F, 3F) - precisely positioned under fluoroscopic control - coil-induced thrombosis thanks to silk or synthetic fibers (except neuro detachable) - MR compatible (Platinum) - collateralization - no repeat intervention (precise placement is mandatory)

8. Embolization materials and substances (liquid, solid) 2. Ethanol Ethiodized oil (Lipiodol) 1mg/kg max. - direct toxic effect on the endothelium activation of the coagulation system - fluoroscopic control

9. Embolization materials and substances (liquid, solid) 3. PVA particles (polyvinyl alcohol) different size (100 – 1000 microns) - thrombosis associated with an inflamatory reaction - fluoroscopic control (mixed with diluted contrast agent)

10. Embolization materials and substances (liquid, solid) 4. Embocept microspheres - temporary embolization for TACE

11. Embolization materials and substances (liquid, solid) 5. Devices Amplatzer Occluding device & Amplatz Vascular Plug (ASD, VSD, PDA) - MR compatible - no repeat intervention (precise placement is mandatory) - self expandible double-disc Nitinol device

12. 2009 - 2013 Our experience Patients n = 10 m/f ratio 8 : 2

13. 2009 - 2013 Our experience Pathological conditions Number of patients Embolization agents Haemorrhage Bleeding1PVA, coil AVM1Coil Tumors Giant cell bone tumor 2PVA, coil Hystiocytoma malignum 1PVA, coil Adenocarcinoma renis recidiv. 1PVA, coil TACEHCC 1 (3 procedures) Lipiodol, Embocept Other conditionsVaricocoela testis3Aethoxysclerol 4%

14. Varicocoela testis embolization PAT. T.N. 23 YRS

15. Varicocoela testis embolization LITERATURE Vascular. 2009 Nov-Dec; 17(3): 129-36. Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy. Bechara CF et all. “… both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles”. Andrologia. 1993 Sep-Oct;25(5):233-7. Surgical ligation vs. angiographic embolization of the vena spermatica: a prospective randomized study for the treatment of varicocele-related infertility. Nieschlag E et all. “…both treatment modalities appear equivalent, whereby embolization has the advantage that it can be performed on an outpatient basis.”

16. Embolization of AVM of the coecum PAT. SH.GJ. 50 YRS WITH MELENA CT angio

17. Embolization of AVM of the coecum PAT. SH.GJ. 50 YRS WITH MELENA Transcatheter angiography

18. Embolization of AVM of the coecum PAT. SH.GJ. 50 YRS WITH MELENA Transcatheter embolization

19. Preoperative tumor embolization PAT. I.N. 37 YRS -GIANT CELL BONE TUMOR CT Diagnostic transcatheter angiography

20. Preoperative tumor embolization PAT. I.N. 37 YRS -GIANT CELL BONE TUMOR

21. Preoperative tumor embolization PAT. I.N. 37 YRS -GIANT CELL BONE TUMOR - postoperative - postoperative

22. Why TACE for Тu (MS) hepatis? NORMAL HEPATIC TISSUE: 75% V.PORTА, 25% А. HEPATICA PROPRIA 1. TU (MS) HEPATIS: 95% А. HEPATICA PROPRIА > 100x local concentration < systemic side effects embolization – selective ischemia, washout delay of citostaticum 1. Breedis and Young 1954; Wang et al. 1994

23. Prospective studies that tumor progression in pts with HCC who underwent TACE is significantly reduced in comparison with pts who did not 2 2. Bruix et al. 2004

24. TACE Indications: surgically non-resectable Tu & Ms lesions inappropriate answer to systemic chemotherapy adequate physical (life expectancy >3m.) Contraindications: poor Karnofsky status (<75%) Hepatic tissue damage (>75%) аlbumin <2mg/dl bilirubin >3mg% infection

25. TACE

26. Inclusive criteria: -no portal thrombosis -no ascites -good hepatic parameters Benefitions: -local anesthesia -outpatient minimum invasive procedure -better quality of life

27. TACE PAT. D.V. 63 YRS -HCC - right hepatic artery - right hepatic artery - left hepatic artery - left hepatic artery

28. TACE Postembolization Syndrom! (abdominal pain, fever, nausea, vomitus) Th: oral antiemetics, analgetics 2 Non-target embolization (a. gastrica deposition – peptic ulcus!) Th: Prophylactic H2 blocker 1 month after TACE 3 2. Zangos et al. 2001; Vogl et al. 2003 3. Hirakawa et al. 1988 (a. cystica deposition – toxic or ishaemic holecystitis!) Th: conservative or surgical

29. Conclusion Transcatheter embolization can be effective curative, adjunctive or palliative procedure for treatment of different pathological conditions in abdomen and pelvis, such as: - hemorrhage (bleeding,) - vascular malformations (AVM, AVF, haemangioma) - other conditions (tumor, varicocoela…)

30. Thank You for Your Attention