EJVES Extra 24 (2012) e5ee6
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Short Report
Successful Superior Thyroid Artery Embolisation Using Microporous Beads S. Speybrouck*, R. Beelen, F. Casselman, L. Maene, I. Bouckenooghe, I. Degrieck Department of Cardiovascular and Thoracic Surgery, OLV Aalst, Moorselbaan 164, 9300 Aalst, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 March 2012 Accepted 16 May 2012
During placement of a central catheter in the left internal jugular vein, an arterial puncture led to an expanding haematoma at the level of the thyroid gland due to an ongoing bleeding fed by the left superior thyroid artery, which was successfully treated by embolisation using beads. The micro-porous structure of these microspheres offered optimal attrition, rigidity, elasticity and durability. These beads provided a controlled, targeted embolisation with a better ability to select the desired end point through choice of size. Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Therapeutic embolisation Microspheres Endovascular procedures
Advances in technology and increased endovascular abilities have stimulated the development of embolisation techniques throughout the peripheral vasculature. Little is found in literature about thyroid artery embolisation. In a post-traumatic setting, strategies and choice of embolic agents are well described, but the thyroid gland demands a different approach than the liver or spleen. This case report demonstrates our approach of a thyroid bleeding after arterial mispuncture for a jugular vein catheter.
(Starclose, Abbott vascular). The whole intervention lasted 45 min with 15 cc contrast and 26 min of fluoroscopy time. No additional open procedure was required. The patient was discharged on the ninth postoperative day and recovered without thyroid dysfunction or recurrent nerve paralysis postoperatively and at follow-up.
Case Description At the end of an aortic valve replacement procedure, a neck haematoma was detected on the left side where a central line placement was initially attempted but failed. An arteriogram revealed an active bleeding fed by the left superior thyroid artery (Fig. 1). Following common femoral puncture with a 16-gauge needle, we aimed for the thyroid region using a 6F destination catheter (90 cm long). We performed a primary catheterisation of the common carotid artery followed by insertion of an angiocath in the external carotid artery and finally, selective catheterisation with a microcatheter (Progreat 2.4, Terumo, 294.14 euro) of the left superior thyroid artery providing sufficient support for bead delivery. During the procedure, an activated clotting time above 200 was reached. Thereafter, an embolisation using beads was successfully performed (Bead Block,R Terumo, 236.27 euro/2cc) (Fig. 2). The puncture site was managed using a closure device
DOI of original article: 10.1016/j.ejvs.2012.05.025. * Corresponding author. Tel.: þ32 53 72 46 99; fax: þ32 53 72 45 52. E-mail address:
[email protected] (S. Speybrouck).
Figure 1. Angiogram showing active bleeding from the thyroid artery.
1533-3167/$ e see front matter Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvsextra.2012.05.001
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900 1200 mm which led to an adequate occlusion. Coils are often advocated in post-traumatic solid organ embolisation but in case of a thyroid bleeding, the risk of tissue damage or even cranial embolisation due to a possible luxation of the coils might be a considerable risk while a targeted embolisation is more easily obtained with microspheres. Complications are related to the angiography itself, for example, haematoma, pseudoaneurysm formation, arterial thrombosis, dissection and embolism or inappropriate injection resulting in (partial) organ ischaemia. This was carefully monitored in our patient but not observed. Care must be taken to evaluate important collaterals during the diagnostic angiogram as these might be a blessing in preventing tissue ischaemia post-procedure, but they might as well continue to perfuse the target lesions especially in case of bilateral lesions. Finally, as always with a new promising technique, longer-term data regarding outcome compared to open techniques are lacking. Conclusion
Figure 2. Angiogram after embolization revealing no active bleeding.
Discussion Arterial puncture, haematoma and pneumothorax are the most common complications during central venous catheter insertion. This occurs more often in patients who have had previous catheters or interventions at the site of insertion, in difficult anatomy or unfavourable body habitus such as obesity.1 In the above-mentioned case, we decided against conservative treatment due to the progressive expansion of the haematoma (7 cm by 6 cm at the time of intervention), which we expected to remain ongoing as anticoagulants needed to be administered for the new mechanical aortic valve. In our interventional strategy, the use of permanent particulate agents or beads was advocated (PVA microspheres or polyvinyl alcohol particles). The micro-porous structure of these microspheres offered optimal attrition, rigidity, elasticity and durability. These qualities are necessary for an easy passage through the catheter and tortuous anatomy without occurrence of fragmentation due to deformation and periprocedural rigours.2,3 Prevention of fragmentation is mandatory as too distal penetration might result in an untargeted embolisation and unwanted tissue damage. These beads provided a controlled, targeted embolisation with a better ability to select the desired end point through choice of size. For this particular case, we used sphere with size ranging from
Advances in technology and increased endovascular abilities have stimulated the development of embolisation techniques for several applications throughout the peripheral vasculature. There are a wide variety of embolic agents, each with its own advantages and required level of expertise for effective use. The beads used in our patient provided a controlled, targeted embolisation with a better ability to select the desired end point through choice of size leading to a true mechanical occlusion. Conflict of Interest All authors disclose any financial or personal interest. Funding None. References 1 Karakiitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Real-time ultrasound guided catheterization of the internal jugular vein: a prospective comparison to the landmark technique in critical care patients. Crit Care 2006;10:R162. 2 Laurent A, Wassef M, Saint Maurice JP, Namur J, Pelage JP, Seron A, et al. Arterial distribution of calibrated tris-acryl gelatin and polyvinyl alcohol microspheres in a sheep kidney model. Invest Radiol 2006;41:8e14. 3 Pelage JP, Laurent A, Wassef M, Bonneau M, Germain D, Rymer R, et al. Acute effects of uterine artery embolization in the sheep: comparison between polyvinyl alcohol particles and calibrated microspheres. Radiology 2002;224:436e45.
