A novel method of inducing thrombosis in target arteries using coronary stents for therapeutic occlusion
Arokiaraj BMC Res Notes
A novel method of inducing thrombosis in target arteries using coronary stents for therapeutic occlusion
Mark Christopher Arokiaraj 0
0 Cardiology, Pondicherry Institute of Medical Sciences , Kalapet , India
Objectives: Peripheral artery embolizations are often required for therapeutic purposes. The therapeutic embolizations are usually performed using embolization particles and coils. These procedures are also associated with complications. Coils and their delivery cables, and the expertise are not always available in all catheterization centers. Hence, a novel, simple controlled technique for arterial closure would be useful in emergency settings. Results: Following is a report of seven cases where embolization was performed successfully on an emergency basis after stenting using coronary stents for better closure of the target artery. Six patients underwent bronchial artery embolization for recurrent massive hemoptysis, and one another patient had pseudoaneurysm following percutaneous nephrolithotomy, and presented with hematuria and persistent and increasing blood discharge in drainage catheter. The stents were deployed in the target artery using 6F Judkin's diagnostic catheter over the 014 wires, which are easily available in all cardiac catheterization laboratories. This is a novel method to establish a metal platform inside the target arteries using coronary stents for better closure of the target arteries in combination with embolization techniques. The procedures were performed as lifesaving measures when small coils and the delivery cables were not available at the time of the procedures.
Peripheral arterial embolization; Coronary stents; Coils
Peripheral arterial embolizations are often required in
routine clinical practice [
], and frequently these
procedures are life-saving. Embolization with coils, glue,
gel foam, polyvinyl alcohol (PVA) particles and
vascular plugs are used frequently for these purposes [
deployment to the target artery is the procedure of choice
]. However, often the expertise and personnel for coil
deployment, and the appropriate delivery cables are not
frequently available in all centers. Hence, a novel, simple
method available in all the centers, which could be used
by any interventionist, would be frequently helpful as a
life saving measure.
Following is a report of seven cases who underwent
stenting and induction of thrombosis in the arteries for
the closure of the artery for therapeutic purposes.
The bronchial artery was identified as a feeder in a patient
who presented with massive hemoptysis. The 45 year old
male had multiple bouts of large volume hemoptysis, and
therefore, bronchial artery embolization was planned.
The bronchial artery was initially embolized with gel
foam and PVA (polyvinyl alcohol 200 μm, Cook Medical)
particles using a Cordis right Judkin’s 6F diagnostic
catheter and iodixanol as contrast. As the artery was large coil
embolization was preferred (Additional file 1: Patient 1a).
For better occlusion as the arterial caliber was large a
coronary stent (Ultimaster 2.5 mm × 18 mm) was deployed
in the feeding bronchial artery (Additional file 2: Patient
1b), and prolonged balloon inflation using the same stent
balloon at low pressure (7 atm). After that embolization
was performed with PVA particles and gel foam
combination (Additional file 3: Patient 1c). Subsequently, the
feeding artery was closed (Fig. 1d and e, Additional file 4).
The patient had severe chest pain immediately after the
procedure, and the pain was controlled with opioid
injections. The patient subsequently recovered, and on
followup, for 11 m there was no hemoptysis.
A 40 year lady, who was a known case of pulmonary
tuberculosis presented with recurrent episodes of
massive hemoptysis. Her chest X-ray showed infiltrates in
the right upper lobe. Bronchial artery embolization was
planned, and a bronchial angiogram was performed.
The angiogram showed a large bronchial artery with
collateral supply in the right upper lobe area (Additional
file 5: Patient 2a). The feeding arterial occlusion was
planned. The bronchial artery was engaged with right
6F Judkin’s diagnostic catheter, and the embolization
was initially performed with gel foam and PVA particles
(300 μm, Additional file 6: Patient 2b). An O14 wire was
inserted, and a stent (Yukon Choice, 2.5 mm × 8 mm)
was deployed in the mid-segment of the bronchial artery
at low pressure (7 atm, Additional file 7: 2c). After that,
another stent (Endeavor Sprint, 2.5 mm × 14 mm) was
deployed in the proximal segment of the artery and
prolonged inflation was given at 6 atm using the stent
balloon (Additional file 8: Patient 2d). After that, the stent
balloon was removed, and PVA particles and gel foam
were injected to ensure complete occlusion of the artery
(Additional file 9: Patient 2e). In this case, since the vessel
was tortuous two short stents were used as a single long
stent may not be trackable easily. The patient had severe
chest discomfort which reduced 1 h after the procedure.
Also, to alleviate her chest pain she required a small dose
of fentanyl. Hemoptysis subsequently subsided, and the
patient’s condition improved. This patient is currently
under follow for 6 m without symptoms.
The 50 year male patient underwent percutaneous
nephrolithotomy due to obstructive nephropathy induced by
a renal calculus. The patient had a percutaneous
drainage catheter, which showed persistent blood discharge in
the drainage catheter, which was progressively
increasing. This patient also had significant hematuria. The renal
angiogram was performed on the patient using 6F
Judkin’s right diagnostic catheter, and the patient had
pulsatile bleeding/pseudoaneurysm in the lower segmental
artery as noticed by extravasation of contrast from the
lower segmental artery (Additional file 10: Patient 3a).
Hence, in this case, a coronary stent was deployed in the
bleeding artery across the pseudoaneurysm using a 014
wire and Nobori 3.0 mm × 15 mm and Cordis 6F right
Judkin’s diagnostic catheter (Fig. 2c, d, Additional file 11:
Patient 3b, Additional file 12: Patient 3c). Prolonged
lowpressure stent balloon inflation was performed for 8 min
at 7 atm pressure using the same stent balloon. After
that, the balloon was removed, and therapeutic
embolization was performed using gel foam and PVA particles
(300 μm, Cook Medical) in the segmental artery using
the JR 6F diagnostic catheter and keeping the 014 wire in
the segmental artery (Fig. 2e, f, Additional file 13: Patient
3d, Additional file 14: Patient e). Angiogram revealed
complete occlusion of the lower polar artery (Fig. 2g,
Additional file 15: Patient 3f ). The patient had severe loin
pain immediately after the procedure, which was
managed with fentanyl injection. Subsequently, the discharge
from the percutaneous drainage was reduced, and the
drainage tube was removed after 3 days. This patient is
being followed up for 1 year, and there are no bleeding
Patient 4 who was a 45 year male presented with
aspergillosis of lung and patient had recurrent episodes of large
volume hemoptysis. He was admitted with another bout
of massive hemoptysis. The patient underwenÚt
bronchial arterial embolization 5 years before, and a 035′ wire
cut segment was placed at the proximal end of the
bronchial artery in the past. Since the patient presented with
recurrent hemoptysis the bronchial arterial embolization
was performed with the similar technique with PVA
particles and gel foam and a coronary stent was placed in the
proximal segment of the artery (Additional file 16: Patient
4a, Additional file 17: Patient 4b, Additional file 18:
Patient 4c, Additional file 19: Patient 4d). The patient is
followed up for 3 months, and there were no other
episodes of hemoptysis. For definitive therapy of
aspergillosis, the patient was not willing for surgery. Hence, he was
discharged with a course of oral itraconazole.
Patient 5 was a 50 year old male, had pulmonary
tuberculosis in the past with destroyed left lung, and this
patient also had a bronchial artery embolization in the
past with gel foam only, which was performed 4 years
before. The patient was admitted with massive
hemoptysis. A large bronchial feeder was identified in
the left upper lobe, and embolization was performed
with PVA particles and followed by gel foam. At the
end of the procedure a stent was placed (endeavor
2.5 mm × 18 mm) at 8 atm, and final closure was
performed with PVA particles followed by gel foam with
good results (Additional file 20: Patient 5a Additional
file 21: Patient 5b, Additional file 22: Patient 5c,
Additional file 23: Patient 5d, Additional file 24: Patient 5e).
The patient had severe chest pain and mild hemoptysis
at the end of the procedure. The patient is being
followed up for 3 months, and there are no episodes of
Patient 6 was a 48 year male, and he had recurrent
episodes of hemoptysis every year for the past 10 years.
During this episode, patient had massive hemoptysis of about
300–400 ml associated with pre-syncope. He was
evaluated by CT chest with contrast and bronchoscopy, which
did not reveal any source of hemoptysis. The bronchial
angiogram revealed extensive broncho-pulmonary
collaterals with a large bronchial artery (3.5 mm).
Embolization was performed with PVA particles, and a small stent
(Yukon Choice 2.25 mm × 18 mm) was placed in the
proximal segment of the artery through a Cordis 6F left
Judkin’s diagnotic catheter. The stent was deployed at 6 atm.
Subsequently, gel foam and PVA particles were injected,
and the vessel was closed (Additional file 25: Patient 6a,
Additional file 26: Patient 6b, Additional file 27: Patient
6c, Additional file 28: Patient 6d). The patient is under
follow up for 2 months without symptoms.
Patient 7 was a 60 year lady who had recurrent episodes
of hemoptysis, and CT chest showed bronchiectasis
of right middle and lower lobes. The patient presented
with massive hemoptysis and patient was taken up for an
urgent bronchial angiogram. The bronchial angiogram
showed a large bronchial artery with distal collaterals.
Embolization was performed with the similar technique,
and a stent was placed (Yukon PC 2.75 mm × 28 mm) at
low-pressure inflation of 6 atm., and complete closure of
the vessel was achieved (Additional file 29: Patient 7a,
Additional file 30: Patient 7b, Additional file 31: Patient
7c, Additional file 32: Patient 7d).
In all the cases the procedures were performed within
24 h of admission to the hospital, and all patients had
significant life-threatening bleeding episodes.
Unfractionated heparin of about 500 to 1000 U in total was used
during the procedures. All procedures were performed
through femoral route, and the sheath was removed
immediately after the procedure. None of the patients
developed peripheral vascular or spinal complications
after the procedures. Also, none of the patients had
episodes of hemoptysis or bleeding on follow-up.
Bronchial artery embolization (BAE) was first described
by Rémy et al. in 1973 [
], and it is now considered a
firstline treatment for most cases of massive hemoptysis [
]. The technique performed in the above seven cases is
a new technique of embolization after deployment of a
stent in the bleeding artery. This is more effective than
embolization with only particles as the stent could provide
a skeleton for a stronger occlusion with a metal platform.
The stent as an embolization platform
Coils are available, and they can be used effectively for the
closure of the arteries. However, coil technique requires
deployment device, coils and also technical expertise in
coil deployments. These may not be available in all
centers especially in the peripheral catheterization
centers. Also, the controlled-release detachable coils are not
available or marketed in all countries. Moreover, the stent
deployments can be very selective to arterial branches
and controlled than coil usage. The deployment of a stent
is simple and fast, and a routine diagnostic 6F right
Judkin’s catheter is available in most centers and easy to use.
Also, frequently these procedures are performed as a
lifesaving method, for example, to prevent a massive uterine
arterial bleeding or massive hemoptysis. Any coronary/
peripheral interventionist in an emergency setting with
limited hardware could use these stents. These stents can
be easily taken through JR 6F diagnostic catheters over
a 014 wire to any selected arteries for therapeutic
purposes. The manipulation of JR diagnostic catheters over
014 wire makes it more selective for injection of
embolization particles than without the wire, as these
catheters can be throttled inside the target artery across the
014 wires (Figs. 1 and 2). Technically coils are relatively
difficult to deploy in interiorly located arteries than
coronary stents, which are more trackable to the target
vessel than coils. Stents also tend to reduce the quantum of
embolization materials, which need to be used with
caution as spillage during injection leads to thrombotic
complications in the neighboring and the distal structures.
(See figure on next page.)
Fig. 2 Segmental renal arterial embolization after stenting closing the pseudoaneurysm in its mid-segment. Panel a shows the aneurysm, panel
b shows placement of stent across pseudoaneurysm, panel c shows stent deployment, and panels d and e show reduction in pseudoaneurysm.
Panels f and g show complete occlusion subsequently after embolisation
Also, micro-catheters are not required using this
technique. Bare metal stents with thicker struts are a better
choice than drug-eluting stents for this purpose though
bare metal stents were not available in our center when
these procedures were performed. A thicker stent, which
is undersized to the artery and low-pressure deployment
leading to under-expansion and usage of multiple stents
are preferable for this purpose. These would ensure a ‘coil
effect’ or tissue reaction essential for restenosis and
promote clot formation in the target vessel [
All seven patients had significant pain immediately
after the injection and occlusion of the artery, which
indicates that the occlusion is complete and the pain
experienced was more than in patients with the injection of the
embolization particles alone. This also indicates the
better efficacy of the procedures in combination with stents
and embolization materials than with the materials alone.
Renal artery embolization is commonly performed
with embolization glues, for example, N-butyl
]. This is the first report of using coronary stents
for selective embolization of the bleeding arteries. This
technique could be used for other peripheral arterial
embolization also, for example, uterine artery
embolization. This is very useful when coil closure method is not
available or not feasible due to lack of technical expertise,
which is not infrequent.
There is no previous report of using coronary stents
for this purpose of therapeutic closure of arteries. The
potential and significant side-effect of any bronchial
artery embolization therapy is paraparesis or
neurological events [
], which was not seen in any of the
patients in this case series with this technique of stent
deployment and embolization.
The number of patients treated by this technique is small,
and in this series, in total, only eight stents were used.
Further studies need to be performed in large numbers of
patients, with long-term follow-up and the results need
to be validated with statistical analysis. Nevertheless, as
a technique it is simple, and any interventionist in any
emergency setting could perform these procedures with
ease and could be life-saving.
The additional video file of the patients showing the initial bronchial
angiogram/feeder using 5F radial Tiger catheter and initial embolization
was performed. Subsequently using 6F Cordis Judkins right diagnostic
catheter over a 014 wire, coronary stents were deployed at low pressure
and final embolization was performed in the artery. Patient 3 underwent
stenting and embolisation to the left lower polar renal artery.
Additional file 1. Patient 1a.
Additional file 2. Patient 1b.
Additional file 3. Patient 1c.
Additional file 4. Patient 1d.
Additional file 5. Patient 2a.
Additional file 6. Patient 2b.
Additional file 7. Patient 2c.
Additional file 8. Patient 2d.
Additional file 9. Patient 2e.
Additional file 10. Patient 3a.
Additional file 11. Patient 3b.
Additional file 12. Patient 3c.
Additional file 13. Patient 3d.
Additional file 14. Patient 3e.
Additional file 15. Patient 3f.
Additional file 16. Patient 4a.
Additional file 17. Patient 4b.
Additional file 18. Patient 4c.
Additional file 19. Patient 4d.
Additional file 20. Patient 5a.
Additional file 21. Patient 5b.
Additional file 22. Patient 5c.
Additional file 23. Patient 5d.
Additional file 24. Patient 5e.
Additional file 25. Patient 6a.
Additional file 26. Patient 6b.
Additional file 27. Patient 6c.
Additional file 28. Patient 6d.
Additional file 29. Patient 7a.
Additional file 30. Patient 7b.
Additional file 31. Patient 7c.
Additional file 32. Patient 7d.
BAE: bronchial artery embolization; PVA: polyvinyl alcohol.
MCA conceived the idea and the method, performed the procedures and
wrote the paper. The author read and approved the final manuscript.
The author declares that there is no competing interests.
Availability of data and materials
All data available in the manuscript and Additional files.
Consent for publication
Informed patient consent obtained in written format.
Ethics approval and consent to participate
Our institution does not require ethical approval for reporting individual cases.
Patient(s) consent for the procedure(s) was obtained in written format.
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