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surgical interventions

Embolization by G.Bertelli

Generality

Embolization is an interventional radiology intervention, which involves the selective occlusion of some blood vessels for therapeutic purposes.

More in detail, the procedure consists in the introduction of autologous emboli or other embolizing materials (eg surgical glue, metal spirals, sclerosing drugs, etc.) through endovascular catheters or direct puncture of the part to be treated.

Embolization can be practiced to resolve numerous conditions, including acute bleeding, vascular diseases, tumors and uterine fibroids. The operation is performed under radiological control, after the administration of a local or general anesthetic.

Embolization can be used alone or in combination with other treatments, such as traditional surgery or radiotherapy.

What's this

Embolization is a non-surgical, minimally invasive procedure that is part of interventional radiology . The method consists in the selective occlusion of one or more arterial or venous vessels that supply the lesion.

Embolization is achieved with the use of particular materials and / or substances, which are introduced through catheters via the endovascular route or direct puncture of the part.

The purpose of embolization is to suppress, definitively or temporarily, the vascular supply of a lesion, a malformation or a tumor neoformation. The result of occlusion of the afferent vessels is ischemic necrosis, with elimination or reduction of mass or wound, without having to resort to traditional surgery.

Interventional radiology: what it is and what it deals with

  • Interventional radiology is a branch of medical radiology that includes all the diagnostic and therapeutic procedures performed under the guidance and control of radiological methods, such as fluoroscopy, ultrasound, computerized tomography and magnetic resonance.
  • Embolization is part of interventional vascular radiology (also called "endovascular surgery"), as is angioplasty, fibrinolysis and stent placement. The objective of these procedures is to obtain equal or better results than the corresponding traditional surgical procedures.

Embolic materials: what and what are they?

The embolizing materials are chosen based on the characteristics of the lesions to be treated to obtain the desired therapeutic effect.

Embolization agents or substances differ in:

  • Physico-chemical characteristics (liquids and solids);
  • Type of occlusion (permanent or temporary).

The main embolizing materials used for the treatment are biocompatible and include:

  • Autologous clots;
  • Sclerosing drugs;
  • Particles of various materials or acrylic polymeric microspheres impregnated with gelatin;
  • Polyvinyl alcohol;
  • Cancellous material (eg gelatin sponge);
  • Cyanoacrylate glues;
  • Different-sized metal spirals (propeller-shaped platinum filaments, stainless steel coils, etc.).

Why do you run

Embolization can be applied to many parts of the body to control or prevent abnormal bleeding . This procedure is considered a valid therapeutic option and is practiced as an alternative to surgery for the management of various pathological conditions.

Health problems that can be treated with embolization include:

  • And acute deaths, examples:
    • Traumatic injuries;
    • Bleeding in the abdomen or pelvis caused by a car accident;
    • Gastrointestinal bleeding of various origins (eg peptic ulcer, hemorrhoids, diverticular disease);
  • Arteriovenous malformations (abnormal connections that can form between the arteries and veins in the circulatory system, in any part of the body including the brain or spinal cord; these lesions cause a sort of "short circuit", completely hindering the circulation of blood and supply of oxygen where it is necessary);
  • Arteriovenous fistulas (bridges connecting arteries and veins);
  • Aneurysms or pseudo -a neurisms (embolization, in this case, serves as an alternative to surgery, to close the aneurysmal sac or block the artery that provides these dilations of the vascular wall);
  • Malignant or benign hypervascular tumors ;
  • Angiomas ;
  • Varicocele ;
  • Hypersplenism ;
  • Uterine fibroids .

The purpose of this method is to selectively suppress the blood supply, causing the occlusion of the vessels afferent to a lesion or a neoformation. Embolization therefore leads to ischemic necrosis.

The vascular occlusion is caused by the introduction by puncture or catheterization of an embolizing material, capable of blocking the blood flow and facilitating thrombogenesis.

Embolization: possible applications

Embolization is a treatment that is used with the aim of:

  • Stop the growth or worsening of the lesion : embolization is curative when applied to the treatment of all benign or pseudo-tumor lesions, such as aneurysmal cysts and angiomas, in order to heal them.
  • Facilitate any surgical intervention : embolization has an adjuvant meaning when it is carried out in order to facilitate the surgical treatment of benign and malignant (locally aggressive) lesions. This approach allows a reduction in the size of the lesion, occluding the vessels that are supplying it with blood, facilitating its removal, as well as being useful for controlling any bleeding and completing the results of the surgery. Embolization can also be used to administer chemotherapy drugs, such as doxorubicin or irinotecan.
  • Reducing pain : embolization can be useful for controlling the aggressiveness of a lesion (especially when the tumor is difficult or impossible to remove) and the related symptoms. The analgesic effect is closely related to ischemic necrosis: a reduction in mass or lesion leads to less compression of neighboring tissues.

Preparation

  • The indication for embolization is placed after a correct diagnosis of the lesion that will allow us to define the morphology, the dimensions and the relationships with the neighboring structures . In the case of tumor growths, in addition to staging, biopsy must always be performed before surgery (after embolization, necrotic tissue could pose histopathological diagnosis problems).
  • Before undergoing embolization, you must be fasting solid foods for at least 8 hours, but drinking small amounts of water is permitted.
  • The patient will go to the X-ray room with a peripheral venous access. In most cases, the procedure is performed under local and anesthesia . Sometimes, epidural anesthesia is practiced (eg embolization of large uterine fibroids) or general, if the maneuvers require extreme delicacy (as in the case of the treatment of a cerebral aneurysm).
  • The embolization procedure takes place in conditions of sterility. The procedure is followed at the angiography of the region, in order to highlight the pathological vascularization.

How to do it

How is Embolization carried out?

  • Embolization with catheterization involves puncturing the femoral artery (alternative access routes are the humeral or axillary ). In order to reach the lesion to be embolized, a thin retrograde catheter is subsequently introduced, under fluoroscopy, ultrasound or other radiological techniques.
  • The catheter is pushed through the vessels to the pathological area to be treated and, through the inoculation of a contrast medium, the type and degree of vascularization of the lesion is accurately assessed (angiography). If from this preliminary examination, the procedure is feasible, the substance or the embolizing material that will occlude the pathological vessels is introduced through the catheter itself.
  • At the end of the procedure, the doctor will perform a control angiography to evaluate the territorial distribution and the quality of the vascular occlusion. After ensuring the success of the devascularization, the doctor takes off the catheter and applies a compressive dressing to the point of entry into the skin.
  • The procedure can be repeated several times after some time. In the absence of complications, a hospital stay of 24-48 hours is sufficient.

Complications and Risks

Embolization is considered a minimally invasive procedure and represents a valid alternative to traditional "open-air" surgery.

However, the method is not without risks:

  • Apart from hematomas (circumscribed blood collections) that represent an event often related to the artery or access vein, the complications are essentially represented by the accidental embolization of non-lesional areas . This event can occur due to the displacement of embolic agents in other vessels . In certain adjacent or distant vascular districts, such as the rachis, this situation can be debilitating, causing ischemic damage, skin ulceration or nerve injury . These consequences are generally small and reversible, but, in more rare cases, can lead to serious functional damage and sometimes require reparative surgical operations.
  • Inoculation of the contrast agent during the procedure may cause some mild adverse reactions (nausea, vomiting and itching) or moderate (diffuse urticaria, facial edema and bronchospasm) and are generally resolved with simple therapeutic measures. In very rare cases, hypotensive shock, pulmonary edema and cardio-respiratory arrest may occur.
  • Angiography related to embolization can also give rise to vagal reactions (nausea, lowering of heart rate and blood pressure, etc.) secondary to the reflexes triggered by the puncture.

Embolization: is it painful?

  • Being a procedure that involves the insertion of a catheter or the inoculation by puncture of an embolic agent, the treatment can cause discomfort and pain.
  • During the post embolization course it is normal to experience a soreness of the treated area, which tends to progressively decrease within about two to three weeks. Rarely, pain can last longer. In these cases, the discomfort can be alleviated with pain medication.

Results

The clinical success of embolization depends on many factors, including the size and location of the lesion or tumor.

Embolization therapy can offer numerous benefits compared to surgical treatments, such as minimal invasiveness, high efficacy in controlling bleeding, minimal risk of infection, faster recovery times and the absence of scars .

What are the advantages and disadvantages of embolization?

PRO

The main advantage of embolization consists in elimination or, if this is not possible, in reducing the lesion to be treated, to improve its state and not having to resort to surgery.

Embolization reduces the operative risk and the success rate is very high, especially with regard to the control of bleeding in emergency situations . This procedure also correlates with fewer complications (about half compared to surgery) and hospital stay is relatively short.

Embolization can be used to treat tumors and vascular malformations that cannot be removed or would pose a great risk if surgery were attempted.

VERSUS

In a small percentage of cases, embolization is not technically possible, since the catheter cannot be positioned appropriately, without the risk of damaging normal tissue.

Sometimes, more embolization interventions are needed to get better results.

If after a successful treatment, the pathology again occurs or progresses towards a deterioration, it is necessary to proceed with other types of intervention.

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