Tmatthews
Contributor
I'm fairly new to IV. I think its so lengthy is it confusing me. Please help with this study:
Procedure: Cerebral angiogram and embolization of multiple left external
carotid artery branches for a left supraorbital renal cell metastasis
Approach: 5 French right common femoral.
Complications: None
Vessels selected and injected:
Right common carotid artery
Left common carotid artery
Left external carotid artery
Left internal maxillary artery
Left anterior deep temporal artery
Left middle meningeal artery
Anterior division left middle meningeal artery
Left superficial temporal artery
Left mid deep temporal artery
Vessels treated: Left anterior deep temporal, mid deep temporal, middle
meningeal, and superficial temporal arteries all embolized with polyvinyl
alcohol particles, 250-350 ? followed by Gelfoam pledgets
Control angiograms: 9
Equipment used: 5 French micropuncture set, 5 French short sheath, a 0.035
Bentson guidewire, 0.035 Terumo guidewire, 5 French vertebral catheter,
echelon 10 microcatheter, Synchro 2 standard microguidewire, PVA 250-350 ?,
Gelfoam pad
CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was
an appropriate candidate for conscious sedation. Adequate sedation was
maintained during the entire procedure by the nurse. Vital signs, pulse
oximetry, and response to verbal commands were monitored and recorded by
the nurse throughout the procedure and the recovery period. The flow sheet
was placed in the medical record including the medications and dosages used.
The patient was taken to the ICU by the ICU nursing team.
PROCEDURE: The risks, benefits, and alternatives to the procedure were
explained to the patient and the family, and written informed consent was
obtained. The patient was placed supine on the angiographic table, and the
right groin was prepped and draped in the usual sterile manner. The skin
and subcutaneous tissues were anesthetized with local anesthesia. Using a
5F micropuncture set the right common femoral artery was punctured and
cannulated and a 5 French arterial sheath was placed over a guidewire. The
sheath was attached to continuous heparinized saline flush. A 5F diagnostic
catheter was placed through the sheath and advanced over a Terumo guidewire
into the aortic arch. Selective catheterization of the following blood
vessels was performed (see below). At the end of the procedure, hemostasis
was achieved by manual compression as the patient was too thin to use a
closure device.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC
ARTERIOGRAMS:
RIGHT COMMON CAROTID ARTERY, CERVICAL: The catheter was used to select the
right common carotid artery. DSA in the AP and lateral views of the cervical
region were performed. The distal common, proximal internal, and imaged
external carotid arteries are normal in caliber. There is mild ASVD at the
origin of the ECA. The carotid bifurcation is widely patent and reversed.
No flow limiting stenosis is seen.
RIGHT COMMON CAROTID ARTERY, CEREBRAL: The catheter remained in the right
common carotid artery. DSA in the AP and lateral oblique views of the
intracranial circulation were performed. The petrous, cavernous and
supraclinoid segments are normal in size, course and contour. There is a
posterior communicating artery with filling of the PCA. The ICA terminates
into the MCA; the ACA trunk is not visualized and is most likely
hypoplastic. There is no significant intracranial atherosclerotic disease.
Dynamic imaging demonstrates numerous intracranial blushes consistent with
bony metastases. The right middle meningeal artery has transfalcine supply
to A small portion of the medial aspect of the left supraorbital tumor. The
intracranial venous structures Opacify appropriately and appear patent.
The right transverse sinus is dominant and the left transverse sinus is
small.
LEFT COMMON CAROTID ARTERY, CERVICAL: The catheter was used to select the
left common carotid artery. DSA in the AP and lateral views of the cervical
region were performed. The distal common and proximal ICA are are normal in
caliber and contour. The origin of the ECA shows a less than 50% stenosis of
the ICA at the origin but is otherwise widely patent.
LEFT COMMON CAROTID ARTERY, CEREBRAL: The catheter remained in the left
common carotid artery. DSA in the AP and lateral views of the intracranial
circulation was performed. The petrous, cavernous and supraclinoid segments
are normal in size, course and contour. There is a small posterior
communicating artery infundibulum that measures 1.5 mm. The ICA terminates
into the MCA and ACA trunks. The right ACA fills from the left via a patent
anterior communicating artery. There is proximal shift of the ACAs
secondary to the orbital region mass. The sylvian point is medially
deviated also. There is no significant intracranial disease. Dynamic
imaging demonstrates a a large in homogeneous tumor blush associated with
the supraorbital mass. Other smaller areas of blush are also noted and all
are consistent with vascular metastases. The intracranial venous structures
opacify appropriately and appear patent.
LEFT EXTERNAL CAROTID ARTERY: The catheter was advanced over the guidewire
into the proximal left external carotid artery. DSA in the AP and lateral
views was performed. There is enlargement of the anterior deep temporal
artery, mid deep temporal artery, middle meningeal artery, and superficial
temporal artery. These vessels all supply the large left supraorbital
osseous metastasis. Inhomogeneous blush is noted throughout the lesion
particularly around its edges. The superficial femoral artery provides the
primary blood supply to the major central portion of the tumor. The
remainder of the external carotid branches are normal.
SUPERSELECTIVE CATHETERIZATION OF THE LEFT ECA BRANCHES, EMBOLIZATION OF THE
ECA BRANCHES SUPPLYING THE TUMOR, CONTROL ANGIOGRAMS:
The vertebral catheter was pulled back into the common carotid artery.
Through a rotating hemostatic valve, the echelon 10 microcatheter was
advanced over a Synchro 2 microguidewire into the proximal portion of the
internal maxillary artery.
LEFT INTERNAL MAXILLARY ARTERY: DSA of the internal maxillary artery was
performed in the AP and lateral views. This vessel shows the multiple
feeders to the tumor including the anterior and mid deep temporal arteries,
and the middle meningeal artery. Reflux into the superficial temporal artery
which also supplies the tumor. The distal IMA vessels are small, with the
infraorbital vessel the largest one seen.
LEFT ANTERIOR DEEP TEMPORAL ARTERY: The microcatheter was advanced over the
microguidewire into the anterior deep temporal artery. DSA in the AP and
lateral views shows extensive tumor blush arising from this vessel primarily
along the lateral surface of the tumor.
Embolization of the anterior deep temporal was performed using PVA
particles. Control angiogram #1 After injection of 3 cc of PVA shows marked
truncation of the tumor blush. A Gelfoam pledget was placed in the vessel at
the end of the PVA embolization.
LEFT MIDDLE MENINGEAL ARTERY: The microcatheter was advanced over the
microguidewire into the middle meningeal artery just proximal to the
posterior division. DSA in the AP and lateral views was performed
ANTERIOR DIVISION, LEFT MMA: The catheter was advanced past the
meningolacrimal artery into the anterior division. DSA in the AP and
lateral views show extensive tumor blush arising from this portion of the
vessel to supply the lateral and inferior portions.
Embolization of the anterior division of the left meningolacrimal artery was
performed using 3 ccs of PVA particles. Control angiogram #2 shows no tumor
blush following this embolization. This was followed by injection of a
Gelfoam pledget. Control angiogram #3 showed no filling of the anterior
division but reflux into the meningolacrimal branch which showed extensive
tumor blush. The microcatheter was pulled back proximal to the
meningolacrimal branch branch and PVA embolization, 2 ccs was performed.
Control angiogram #4 shows no filling of this portion of the tumor after
embolization. Another Gelfoam pledget was placed in the middle meningeal
artery.
LEFT SUPERFICIAL TEMPORAL ARTERY: The catheter was pulled back into the
distal ECA and was advanced over the Synchro wire into the superficial
temporal artery. DSA in the AP and lateral views shows extensive tumor blush
primarily of the central portion from this injection. The majority of the
tumor is fed by this artery.
PVA embolization, 7 cc was performed. Control angiogram #5 shows no filling
of the central portion of the tumor and sluggish flow in the vessel. A
Gelfoam pledget was injected. Control angiogram #6 shows truncation of the
vessel where it enters into the tumor.
LEFT MID DEEP TEMPORAL ARTERY: The microcatheter was pulled back into the
distal external carotid artery, and under roadmap guidance was advanced over
the microguidewire into the mid deep temporal artery. DSA in the AP and
lateral views shows tumor blush involving the lateral aspect of the mass.
PVA embolization of this vessel, 2 cc, was performed. This was followed by
placement of a Gelfoam pledget.
The microcatheter was pulled back into the left internal maxillary artery
and a control angiogram (#7) was performed. This shows no filling of the
tumor from the 3 IMA branches. The catheter was then pulled back into the
distal external carotid artery and a control angiogram of the ECA (#8)
showed no filling of the tumor from the IMA branches or the superficial
temporal artery. The microcatheter was removed and a final control angiogram
(#9) from the 5 French vertebral catheter in the left common carotid artery
was performed. This control angiogram shows that there is no tumor blush
from the external carotid branches. There is continued filling of the
anterior and superior portion of the tumor from the anterior falcine artery
and the supraorbital branch of the ophthalmic artery. These could not be
safely embolized as they arise from the ophthalmic artery.
IMPRESSION:
1. Large left supraorbital calvarial vascular tumor as described above
consistent with a renal cell metastasis. The component that is fed by the
external carotid artery branches was embolized to completion. The remaining
portion of the tumor blush is fed by ophthalmic artery branches which cannot
be safely embolized.
2. Multiple osseous vascular metastases identified throughout the calvarium.
The right-sided lesions are more numerous than the left and are primarily
tiny or small.
3. Vascular displacement of the ACA (proximal shift) and MCA (medial
deviation of the sylvian point) by the tumor is noted.
2. No significant atherosclerotic disease. The right ACA is fed by the left
ACA across a patent anterior to indicating artery.
Procedure: Cerebral angiogram and embolization of multiple left external
carotid artery branches for a left supraorbital renal cell metastasis
Approach: 5 French right common femoral.
Complications: None
Vessels selected and injected:
Right common carotid artery
Left common carotid artery
Left external carotid artery
Left internal maxillary artery
Left anterior deep temporal artery
Left middle meningeal artery
Anterior division left middle meningeal artery
Left superficial temporal artery
Left mid deep temporal artery
Vessels treated: Left anterior deep temporal, mid deep temporal, middle
meningeal, and superficial temporal arteries all embolized with polyvinyl
alcohol particles, 250-350 ? followed by Gelfoam pledgets
Control angiograms: 9
Equipment used: 5 French micropuncture set, 5 French short sheath, a 0.035
Bentson guidewire, 0.035 Terumo guidewire, 5 French vertebral catheter,
echelon 10 microcatheter, Synchro 2 standard microguidewire, PVA 250-350 ?,
Gelfoam pad
CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was
an appropriate candidate for conscious sedation. Adequate sedation was
maintained during the entire procedure by the nurse. Vital signs, pulse
oximetry, and response to verbal commands were monitored and recorded by
the nurse throughout the procedure and the recovery period. The flow sheet
was placed in the medical record including the medications and dosages used.
The patient was taken to the ICU by the ICU nursing team.
PROCEDURE: The risks, benefits, and alternatives to the procedure were
explained to the patient and the family, and written informed consent was
obtained. The patient was placed supine on the angiographic table, and the
right groin was prepped and draped in the usual sterile manner. The skin
and subcutaneous tissues were anesthetized with local anesthesia. Using a
5F micropuncture set the right common femoral artery was punctured and
cannulated and a 5 French arterial sheath was placed over a guidewire. The
sheath was attached to continuous heparinized saline flush. A 5F diagnostic
catheter was placed through the sheath and advanced over a Terumo guidewire
into the aortic arch. Selective catheterization of the following blood
vessels was performed (see below). At the end of the procedure, hemostasis
was achieved by manual compression as the patient was too thin to use a
closure device.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC
ARTERIOGRAMS:
RIGHT COMMON CAROTID ARTERY, CERVICAL: The catheter was used to select the
right common carotid artery. DSA in the AP and lateral views of the cervical
region were performed. The distal common, proximal internal, and imaged
external carotid arteries are normal in caliber. There is mild ASVD at the
origin of the ECA. The carotid bifurcation is widely patent and reversed.
No flow limiting stenosis is seen.
RIGHT COMMON CAROTID ARTERY, CEREBRAL: The catheter remained in the right
common carotid artery. DSA in the AP and lateral oblique views of the
intracranial circulation were performed. The petrous, cavernous and
supraclinoid segments are normal in size, course and contour. There is a
posterior communicating artery with filling of the PCA. The ICA terminates
into the MCA; the ACA trunk is not visualized and is most likely
hypoplastic. There is no significant intracranial atherosclerotic disease.
Dynamic imaging demonstrates numerous intracranial blushes consistent with
bony metastases. The right middle meningeal artery has transfalcine supply
to A small portion of the medial aspect of the left supraorbital tumor. The
intracranial venous structures Opacify appropriately and appear patent.
The right transverse sinus is dominant and the left transverse sinus is
small.
LEFT COMMON CAROTID ARTERY, CERVICAL: The catheter was used to select the
left common carotid artery. DSA in the AP and lateral views of the cervical
region were performed. The distal common and proximal ICA are are normal in
caliber and contour. The origin of the ECA shows a less than 50% stenosis of
the ICA at the origin but is otherwise widely patent.
LEFT COMMON CAROTID ARTERY, CEREBRAL: The catheter remained in the left
common carotid artery. DSA in the AP and lateral views of the intracranial
circulation was performed. The petrous, cavernous and supraclinoid segments
are normal in size, course and contour. There is a small posterior
communicating artery infundibulum that measures 1.5 mm. The ICA terminates
into the MCA and ACA trunks. The right ACA fills from the left via a patent
anterior communicating artery. There is proximal shift of the ACAs
secondary to the orbital region mass. The sylvian point is medially
deviated also. There is no significant intracranial disease. Dynamic
imaging demonstrates a a large in homogeneous tumor blush associated with
the supraorbital mass. Other smaller areas of blush are also noted and all
are consistent with vascular metastases. The intracranial venous structures
opacify appropriately and appear patent.
LEFT EXTERNAL CAROTID ARTERY: The catheter was advanced over the guidewire
into the proximal left external carotid artery. DSA in the AP and lateral
views was performed. There is enlargement of the anterior deep temporal
artery, mid deep temporal artery, middle meningeal artery, and superficial
temporal artery. These vessels all supply the large left supraorbital
osseous metastasis. Inhomogeneous blush is noted throughout the lesion
particularly around its edges. The superficial femoral artery provides the
primary blood supply to the major central portion of the tumor. The
remainder of the external carotid branches are normal.
SUPERSELECTIVE CATHETERIZATION OF THE LEFT ECA BRANCHES, EMBOLIZATION OF THE
ECA BRANCHES SUPPLYING THE TUMOR, CONTROL ANGIOGRAMS:
The vertebral catheter was pulled back into the common carotid artery.
Through a rotating hemostatic valve, the echelon 10 microcatheter was
advanced over a Synchro 2 microguidewire into the proximal portion of the
internal maxillary artery.
LEFT INTERNAL MAXILLARY ARTERY: DSA of the internal maxillary artery was
performed in the AP and lateral views. This vessel shows the multiple
feeders to the tumor including the anterior and mid deep temporal arteries,
and the middle meningeal artery. Reflux into the superficial temporal artery
which also supplies the tumor. The distal IMA vessels are small, with the
infraorbital vessel the largest one seen.
LEFT ANTERIOR DEEP TEMPORAL ARTERY: The microcatheter was advanced over the
microguidewire into the anterior deep temporal artery. DSA in the AP and
lateral views shows extensive tumor blush arising from this vessel primarily
along the lateral surface of the tumor.
Embolization of the anterior deep temporal was performed using PVA
particles. Control angiogram #1 After injection of 3 cc of PVA shows marked
truncation of the tumor blush. A Gelfoam pledget was placed in the vessel at
the end of the PVA embolization.
LEFT MIDDLE MENINGEAL ARTERY: The microcatheter was advanced over the
microguidewire into the middle meningeal artery just proximal to the
posterior division. DSA in the AP and lateral views was performed
ANTERIOR DIVISION, LEFT MMA: The catheter was advanced past the
meningolacrimal artery into the anterior division. DSA in the AP and
lateral views show extensive tumor blush arising from this portion of the
vessel to supply the lateral and inferior portions.
Embolization of the anterior division of the left meningolacrimal artery was
performed using 3 ccs of PVA particles. Control angiogram #2 shows no tumor
blush following this embolization. This was followed by injection of a
Gelfoam pledget. Control angiogram #3 showed no filling of the anterior
division but reflux into the meningolacrimal branch which showed extensive
tumor blush. The microcatheter was pulled back proximal to the
meningolacrimal branch branch and PVA embolization, 2 ccs was performed.
Control angiogram #4 shows no filling of this portion of the tumor after
embolization. Another Gelfoam pledget was placed in the middle meningeal
artery.
LEFT SUPERFICIAL TEMPORAL ARTERY: The catheter was pulled back into the
distal ECA and was advanced over the Synchro wire into the superficial
temporal artery. DSA in the AP and lateral views shows extensive tumor blush
primarily of the central portion from this injection. The majority of the
tumor is fed by this artery.
PVA embolization, 7 cc was performed. Control angiogram #5 shows no filling
of the central portion of the tumor and sluggish flow in the vessel. A
Gelfoam pledget was injected. Control angiogram #6 shows truncation of the
vessel where it enters into the tumor.
LEFT MID DEEP TEMPORAL ARTERY: The microcatheter was pulled back into the
distal external carotid artery, and under roadmap guidance was advanced over
the microguidewire into the mid deep temporal artery. DSA in the AP and
lateral views shows tumor blush involving the lateral aspect of the mass.
PVA embolization of this vessel, 2 cc, was performed. This was followed by
placement of a Gelfoam pledget.
The microcatheter was pulled back into the left internal maxillary artery
and a control angiogram (#7) was performed. This shows no filling of the
tumor from the 3 IMA branches. The catheter was then pulled back into the
distal external carotid artery and a control angiogram of the ECA (#8)
showed no filling of the tumor from the IMA branches or the superficial
temporal artery. The microcatheter was removed and a final control angiogram
(#9) from the 5 French vertebral catheter in the left common carotid artery
was performed. This control angiogram shows that there is no tumor blush
from the external carotid branches. There is continued filling of the
anterior and superior portion of the tumor from the anterior falcine artery
and the supraorbital branch of the ophthalmic artery. These could not be
safely embolized as they arise from the ophthalmic artery.
IMPRESSION:
1. Large left supraorbital calvarial vascular tumor as described above
consistent with a renal cell metastasis. The component that is fed by the
external carotid artery branches was embolized to completion. The remaining
portion of the tumor blush is fed by ophthalmic artery branches which cannot
be safely embolized.
2. Multiple osseous vascular metastases identified throughout the calvarium.
The right-sided lesions are more numerous than the left and are primarily
tiny or small.
3. Vascular displacement of the ACA (proximal shift) and MCA (medial
deviation of the sylvian point) by the tumor is noted.
2. No significant atherosclerotic disease. The right ACA is fed by the left
ACA across a patent anterior to indicating artery.