Gefäßverschließende Methoden (Embolotherapie)

Das therapeutische Spektrum von Embolisationen hat in den letzten Jahrzehnten deutlich zugenommen. Die Vielfalt heute verfügbarer Embolisationsmaterialien und -techniken erfordern genaue Kenntnisse über den Freisetzungsmechanismus, die Embolisationsebene, das Wirkprinzip und die potenziellen Nebenwirkungen. Dieser Artikel soll einen Überblick über die verschiedenen modernen Embolisationsmaterialien und ihre Einsatzbereiche geben.

Kernaussagen

• Die möglichen Indikationen für den Einsatz der Embolisationstherapie haben in den letzten Jahren deutlich zugenommen ([Tab. 1]). Profunde Kenntnisse über Embolisationsebene, Wirkprinzip, Freisetzungsmechanismus und Nebenwirkung der verschiedenen Materialien sind mittlerweile unerlässlich.

• Plugs und Coils eignen sich vor allem für den Verschluss großer bis mittelgroßer Gefäße. Sie benötigen allerdings immer eine funktionierende Blutgerinnung.

• Partikuläre Embolisationsmaterialien finden vor allem in der Embolisation gutartiger und maligner Tumoren Anwendung, da sie tief in das Gewebe eindringen können. Einige Partikel können mit einem Chemotherapeutikum beladen werden. Das resorbierbare Gelfoam eignet sich zur Blutungsembolisation.

• Flüssigembolisate sind vielseitig einsetzbar – vor allem Endoleaks und arteriovenöse Malformationen können hiermit gezielt und sicher behandelt werden.

• Sklerosierungsmittel spielen eine wichtige Rolle in der interventionellen Behandlung angeborener Slow-Flow-Gefäßmalformationen.

Schlüsselwörter

Embolisierung - Embolisationstherapie - Embolisate - interventioneller Gefäßverschluss - Coils - transarterielle Chemoembolisation

Key words

embolization - embolic agents - endovascular occlusion - coils - transarterial chemoembolization

• Literatur

• 1 Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Roentgenol Radium Ther Nucl Med 1975; 124: 428-435
• 2 Muller-Wille R, Uller W, Gossmann H. et al. Inferior mesenteric artery embolization before endovascular aortic aneurysm repair using amplatzer vascular plug type 4. Cardiovasc Intervent Radiol 2014; 37: 928-934 doi:10.1007/s00270-013-0762-4
• 3 Wang W, Li H, Tam MD. et al. The amplatzer vascular plug: a review of the device and its clinical applications. Cardiovasc Intervent Radiol 2012; 35: 725-740 doi:10.1007/s00270-012-0387-z
• 4 Scharf G, Wohlgemuth WA, Stroszczynski C. et al. [An unusual cause for hemoptysis - endovascular occlusion of an aorta originating lung artery]. Rofo 2016; 188: 97-99 doi:10.1055/s-0035-1553369
• 5 Wohlgemuth WA, Muller-Wille R, Teusch VI. et al. The retrograde transvenous push-through method: a novel treatment of peripheral arteriovenous malformations with dominant venous outflow. Cardiovasc Intervent Radiol 2015; 38: 623-631 doi:10.1007/s00270-015-1063-x
• 6 Wang W, Tam MD, Spain J. et al. Gelfoam-assisted amplatzer vascular plug technique for rapid occlusion in proximal splenic artery embolization. AJR Am J Roentgenol 2013; 200: 677-681 doi:10.2214/AJR.12.8949
• 7 Kickuth R, Dick F, Triller J. et al. Internal iliac artery embolization before endovascular repair of aortoiliac aneurysms with a nitinol vascular occlusion plug. J Vasc Interv Radiol 2007; 18: 1081-1087 doi:10.1016/j.jvir.2007.06.013
• 8 Vandy F, Criado E, Upchurch jr. GR. et al. Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair. J Vasc Surg 2008; 48: 1121-1124 doi:10.1016/j.jvs.2008.06.002
• 9 Pech M, Kraetsch A, Wieners G. et al. Embolization of the gastroduodenal artery before selective internal radiotherapy: a prospectively randomized trial comparing platinum-fibered microcoils with the Amplatzer Vascular Plug II. Cardiovasc Intervent Radiol 2009; 32: 455-461 doi:10.1007/s00270-008-9498-y
• 10 Pattynama PM, Wils A, van der Linden E. et al. Embolization with the Amplatzer Vascular Plug in TIPS patients. Cardiovasc Intervent Radiol 2007; 30: 1218-1221 doi:10.1007/s00270-007-9089-3
• 11 Basile A, Marletta G, Tsetis D. et al. The Amplatzer vascular plug also for ovarian vein embolization. Cardiovasc Intervent Radiol 2008; 31: 446-447 doi:10.1007/s00270-007-9235-y
• 12 Hart JL, Aldin Z, Braude P. et al. Embolization of pulmonary arteriovenous malformations using the Amplatzer vascular plug: successful treatment of 69 consecutive patients. Eur Radiol 2010; 20: 2663-2670 doi:10.1007/s00330-010-1851-2
• 13 Boatta E, Jahn C, Canuet M. et al. Pulmonary Arteriovenous Malformations Embolized Using a Micro Vascular Plug System: Technical Note on a Preliminary Experience. Cardiovasc Intervent Radiol 2017; 40: 296-301 doi:10.1007/s00270-016-1493-0
• 14 Kickuth R, Anderson S, Kocovic L. et al. Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery. J Vasc Interv Radiol 2006; 17: 791-799 doi:10.1097/01.RVI.0000217929.35607.15
• 15 Suzuki K, Suzuki R, Takigawa T. et al. A Single Center Experience with Coil Embolization for Cerebral Aneurysms Greater than 10 mm in the Internal Carotid Artery. Neurol Med Chir (Tokyo) 2017; 57: 231-237 doi:10.2176/nmc.oa.2016-0176
• 16 White PM, Raymond J. Endovascular coiling of cerebral aneurysms using “bioactive” or coated-coil technologies: a systematic review of the literature. AJNR Am J Neuroradiol 2009; 30: 219-226 doi:10.3174/ajnr.A1324
• 17 Pfister K, Kasprzak PM, Jung EM. et al. Contrast-enhanced ultrasound to evaluate organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms. Clin Hemorheol Microcirc 2016; 64: 689-698 doi:10.3233/CH-168003
• 18 Kopetz S, Jimenez C, Tu SM. et al. Pulmonary arteriovenous fistula in a patient with renal cell carcinoma. Eur Respir J 2007; 29: 813-815 doi:10.1183/09031936.00077106
• 19 Stampfl S, Bellemann N, Stampfl U. et al. Inflammation and recanalization of four different spherical embolization agents in the porcine kidney model. J Vasc Interv Radiol 2008; 19: 577-586 doi:10.1016/j.jvir.2008.01.011
• 20 Lee TM, Vargas A, Dua S. et al. Cerebral Infarctions Following Palliative Transarterial Chemoembolization with Embozene of a Vertebral Body Metastatic Tumor. J Stroke Cerebrovasc Dis 2017; 26: e224-e225 doi:10.1016/j.jstrokecerebrovasdis.2017.08.005
• 21 Brown KT, Do RK, Gonen M. et al. Randomized Trial of Hepatic Artery Embolization for Hepatocellular Carcinoma Using Doxorubicin-Eluting Microspheres Compared With Embolization With Microspheres Alone. J Clin Oncol 2016; 34: 2046-2053 doi:10.1200/JCO.2015.64.0821
• 22 Jander HP, Russinovich NA. Transcatheter gelfoam embolization in abdominal, retroperitoneal, and pelvic hemorrhage. Radiology 1980; 136: 337-344 doi:10.1148/radiology.136.2.6967615
• 23 Travis T, Monsky WL, London J. et al. Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol 2008; 19: 840-847 doi:10.1016/j.jvir.2008.02.011
• 24 Wiggermann P, Heibl M, Niessen C. et al. Degradable starch microspheres transarterial chemoembolisation (DSM-TACE) of HCC: Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based evaluation of therapeutic efficacy using a novel perfusion software. Clin Hemorheol Microcirc 2012; 52: 123-129 doi:10.3233/CH-2012-1590
• 25 Schicho A, Pereira PL, Haimerl M. et al. Transarterial chemoembolization (TACE) with degradable starch microspheres (DSM) in hepatocellular carcinoma (HCC): multi-center results on safety and efficacy. Oncotarget 2017; 8: 72613-72620 doi:10.18632/oncotarget.19997
• 26 Germano IM, Davis RL, Wilson CB. et al. Histopathological follow-up study of 66 cerebral arteriovenous malformations after therapeutic embolization with polyvinyl alcohol. J Neurosurg 1992; 76: 607-614 doi:10.3171/jns.1992.76.4.0607
• 27 Derdeyn CP, Moran CJ, Cross DT. et al. Polyvinyl alcohol particle size and suspension characteristics. AJNR Am J Neuroradiol 1995; 16: 1335-1343
• 28 Choe DH, Han MH, Kang GH. et al. An experimental study of embolic effect according to infusion rate and concentration of suspension in transarterial particulate embolization. Invest Radiol 1997; 32: 260-267
• 29 Pelage JP, Le Dref O, Soyer P. et al. Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 2000; 215: 428-431 doi:10.1148/radiology.215.2.r00ma11428
• 30 Kickuth R, Waldherr C, Hoppe H. et al. Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization. AJR Am J Roentgenol 2008; 191: W240-W247 doi:10.2214/AJR.07.4037
• 31 Layton KF, Kallmes DF, Gray LA. et al. Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia. AJNR Am J Neuroradiol 2007; 28: 885-888
• 32 Pelage JP, Le Dref O, Beregi JP. et al. Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids. J Vasc Interv Radiol 2003; 14: 15-20
• 33 Verret V, Ghegediban SH, Wassef M. et al. The arterial distribution of Embozene and Embosphere microspheres in sheep kidney and uterus embolization models. J Vasc Interv Radiol 2011; 22: 220-228 doi:10.1016/j.jvir.2010.10.021
• 34 Sluzewski M, van Rooij WJ, Lohle PN. et al. Embolization of meningiomas: comparison of safety between calibrated microspheres and polyvinyl-alcohol particles as embolic agents. AJNR Am J Neuroradiol 2013; 34: 727-729 doi:10.3174/ajnr.A3311
• 35 Stampfl U, Radeleff B, Sommer C. et al. Midterm results of uterine artery embolization using narrow-size calibrated embozene microspheres. Cardiovasc Intervent Radiol 2011; 34: 295-305 doi:10.1007/s00270-010-9986-8
• 36 Richter G, Radeleff B, Stroszczynski C. et al. Safety and Feasibility of Chemoembolization with Doxorubicin-Loaded Small Calibrated Microspheres in Patients with Hepatocellular Carcinoma: Results of the MIRACLE I Prospective Multicenter Study. Cardiovasc Intervent Radiol 2018; 41: 587-593 doi:10.1007/s00270-017-1839-2
• 37 Yata S, Ihaya T, Kaminou T. et al. Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2013; 24: 422-431 doi:10.1016/j.jvir.2012.11.024
• 38 Loh Y, Duckwiler GR. Onyx Trial I. A prospective, multicenter, randomized trial of the Onyx liquid embolic system and N-butyl cyanoacrylate embolization of cerebral arteriovenous malformations. Clinical article. J Neurosurg 2010; 113: 733-741 doi:10.3171/2010.3.JNS09370
• 39 Wajswol E, Jazmati T, Contractor S. et al. Portal Vein Embolization Utilizing N-Butyl Cyanoacrylate for Contralateral Lobe Hypertrophy Prior to Liver Resection: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2018; DOI: 10.1007/s00270-018-1964-6.
• 40 Wohlgemuth WA, Uller W, Muller-Wille R. Liquid embolic agents – Onyx as problem solver. Radiologe 2013; 53: 223-229 doi:10.1007/s00117-012-2421-1
• 41 Wildgruber M, Muller-Wille R, Busch V. et al. Severe Adverse Reaction During DMSO Injection for Onyx Embolization of a Thoracic Type II Endoleak. Cardiovasc Intervent Radiol 2016; 39: 144-145 doi:10.1007/s00270-015-1187-z
• 42 Muller-Wille R, Heiss P, Herold T. et al. Endovascular treatment of acute arterial hemorrhage in trauma patients using ethylene vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol 2012; 35: 65-75 doi:10.1007/s00270-011-0134-x
• 43 Ayx I, Muller-Wille R, Wohlgemuth WA. et al. Treatment of Acute Hemoptysis by Bronchial Artery Embolization with the Liquid Embolic Agent Ethylene Vinyl Alcohol Copolymer. J Vasc Interv Radiol 2017; 28: 825-831 doi:10.1016/j.jvir.2016.12.1226
• 44 Rennert J, Herold T, Schreyer AG. et al. [Evaluation of a liquid embolization agent (Onyx) for transcatheter embolization for renal vascular lesions]. Rofo 2009; 181: 996-1001 doi:10.1055/s-0028-1109741
• 45 Muller-Wille R, Wohlgemuth WA, Heiss P. et al. Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol 2013; 36: 1288-1295 doi:10.1007/s00270-013-0567-5
• 46 Namazi MH, Khaheshi I, Serati AR. et al. The Safety of Using Large Amount (30 cc) of Onyx (Ethylene-vinyl Alcohol Copolymer) for the Treatment of Large Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm. Int J Angiol 2016; 25: e169-e172 doi:10.1055/s-0036-1593826
• 47 Muller-Wille R, Wildgruber M, Sadick M. et al. Vascular Anomalies (Part II): Interventional Therapy of Peripheral Vascular Malformations. Rofo 2018; DOI: 10.1055/s-0044-101266.
• 48 Lee BB, Do YS, Byun HS. et al. Advanced management of venous malformation with ethanol sclerotherapy: mid-term results. J Vasc Surg 2003; 37: 533-538 doi:10.1067/mva.2003.91
• 49 Cho SK, Do YS, Shin SW. et al. Arteriovenous malformations of the body and extremities: analysis of therapeutic outcomes and approaches according to a modified angiographic classification. J Endovasc Ther 2006; 13: 527-538 doi:10.1583/05-1769.1
• 50 Wohlgemuth WA, Muller-Wille R, Teusch V. et al. Ethanolgel sclerotherapy of venous malformations improves health-related quality-of-life in adults and children – results of a prospective study. Eur Radiol 2017; 27: 2482-2488 doi:10.1007/s00330-016-4603-0
• 51 Horbach SE, Lokhorst MM, Saeed P. et al. Sclerotherapy for low-flow vascular malformations of the head and neck: A systematic review of sclerosing agents. J Plast Reconstr Aesthet Surg 2016; 69: 295-304 doi:10.1016/j.bjps.2015.10.045