Clinical Experience - Okami Medical

Clinical Experience

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implants in a wide range of cases

Case Studies

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• GDA Ulcer Embolization
• Pulmonary Arteriovenous Malformations
• Treatment of PAVM Persistence After Coil Embolization

• Splenic Artery Sacrifice for Aneurysm Embolization
• Pulmonary Arteriovenous Malformation
• Emergent Uterine Artery Embolization
• Abdominal Hematoma

GDA Ulcer Embolization

Harris Chengazi, M.D.
Vascular and Interventional Physician
Great Lakes Medical Imaging

A 69-year-old male with a history of HTN, BPH, GERD and AFib on Pradaxa presented to the hospital with syncope and occasional black stools.
Angiography demonstrated frank active arterial extravasation from the known duodenal ulcer.
The microcatheter was navigated beyond the site of bleeding to select the gastroepiploic and superior pancreaticoduodenal arteries, and these were successfully and rapidly occluded with LOBO-3 to prevent back filling of the GDA.
Immediate post embolization angiography showed complete occlusion of the gastroduodenal artery.
The LOBO occluder allowed for rapid and accurate embolization with near immediate occlusion.

Three days after embolization CTA demonstrates occlusion of the GDA and minimal artifact from the LOBO devices.

Figure 1: Angiography from the GDA (black arrow) demonstrates frank abnormality of the vessel at site of ulcer (white arrow) with active bleeding (red arrow). The gastroepiploic artery (blue arrows) and superior pancreaticoduodenal artery (yellow arrow) are seen distal to the site of active bleeding.

Figure 2: Post embolization angiography from the GDA demonstrates 3 LOBO-3 occluders. The superior pancreaticoduodenal artery (yellow bracket) and gastroepiploic artery (blue bracket) are occluded to prevent back filling of the gastroduodenal artery. A LOBO-3 device is also deployed across the site of ulceration (white bracket). The previously seen ulcer and active bleeding are no longer seen.

Figure 3: CTA with 3D reconstruction performed 3 days after embolization shows the GDA (white arrow) with cutoff at the level of the 3 LOBO devices (brackets). The radiopaque markers well delineate the LOBO devices and the embolized vessel with minimal artifact.

Pulmonary Arteriovenous Malformations

Brian Funaki, M.D.
Professor and Chief Vascular and Interventional Radiology
University of Chicago Medicine

A 56-year-old woman newly diagnosed with hereditary hemorrhagic telangiectasia was found to have multiple pulmonary arteriovenous malformations.
Patients with this disorder can suffer brain abscess, stroke, and myocardial infarction from paradoxic emboli to the systemic circulation.
Four LOBOs were deployed with immediate and complete occlusion of the PAVMs.
The LOBO device has excellent radial strength and an overall geometry that enables precise deployment and prevents migration through the malformation.
Following embolization, the patient remained asymptomatic and was discharged 2 hours after the procedure to home.
A CTA was obtained 6 months after PAVM embolization showing complete and durable occlusion of multiple malformations.

Vascular plugs have advantages over coils and are preferred as the embolic of choice of many interventional radiologists treating patients with these lesions. The LOBO device has many desirable attributes including immediate occlusion, flexible sizing, precise placement, radial strength to preclude migration, and excellent trackability in tortuous vessels.

Figure 1: Digital subtraction angiogram showing 4 PAVMs in the right lower lobe (red arrows).

Figure 2: Angiogram showing deployed LOBO-5 completely occluding PAVM.

Figure 3: Digital subtraction pulmonary angiogram showing complete occlusion of all 4 PAVMs.

Treatment of PAVM Persistence After Coil Embolization

Brian Funaki, M.D.
Professor and Chief Vascular and Interventional Radiology
University of Chicago Medicine

A previously healthy 35-year-old man suffered 3 consecutive strokes over several months.
Discovered to have a pulmonary arteriovenous malformation and paradoxic emboli.
He underwent coil embolization at an outside hospital. After CT scanning, persistent flow through the coil pack into the malformation was revealed.
Embolization was planned using LOBO (LOw-profile Braided Occluder). The LOBO device was required to track through tortuous anatomy; the LOBO device articulates which allows the occluder to track around curves without causing catheter retraction.
A single LOBO-3 vascular occluder was deployed immediately adjacent to the coil pack. There was complete and immediate occlusion of the malformation.
Total fluoroscopy time was 18.4 minutes and air kerma was 1124 mGy. The patient was discharged without further intervention and was asymptomatic on 1 week follow up.

The LOBO device has many desirable attributes including immediate occlusion, flexible sizing, precise placement, radial strength to preclude migration, reduced streak artifact on follow up CT, and excellent trackability in tortuous vessels.

Figure 1: Digital subtraction angiogram confirming CTA finding operfusion (red arrow) through coil pack.

Figure 2: Fluoroscopic image showing deployed LOBO-3.

Figure 3: Subselective angiogram showing occlusion of PAVM.

Splenic Artery Sacrifice for Aneurysm Embolization

Raj Pyne, MD, FSIR
Interventional Radiologist
Rochester Regional Health

A 55-year-old female with a known history of HTN and hypothyroidism presented for evaluation of a splenic artery aneurysm.
This led to a CT angiography of the abdomen, which confirmed a 2.2 cm splenic artery aneurysm that was partially thrombosed.
Although it was partially thrombosed, the aneurysm demonstrated internal patent flow through a tortuous tubular channel directly subjacent to the thinned, dilated splenic artery wall.
A LOBO-7 vascular occluder was selected for placement.
Deployment of the LOBO-7 vascular occluder was advantageous given the process of simply unsheathing it as opposed to pushing it out and hoping it forms in proper position.
Follow-up CTA demonstrated complete and successful embolization of the distal splenic artery with occlusion of the aneurysm but sparing of nearly all the splenic parenchyma.

LOBO occluders are a newer option which provide significant advantages in the splenic artery vasculature.

Figure 1: Axial and coronal CTA images demonstrate a 2.2 cm fusiform aneurysm in the distal splenic artery near the splenic hilum which is partially thrombosed (yellow arrows). The aneurysm demonstrates internal flow through a tortuous tubular channel directly subjacent to the thinned, dilated splenic artery wall. This has demonstrated interval growth over 3 years.

Figure 2: Angiography just proximal to the splenic hilar aneurysm after advancing the Envoy catheter (left) confirms optimal position for LOBO deployment. Magnified view (right) while advancing the LOBO-7 vascular occluder (ends of the LOBO denoted by two radiopaque markers near the arrow) shows great trackability of the device to the desired location.

Figure 3: Completion angiography 3 minutes later (left) demonstrating the LOBO-7 remaining in precise position without forward migration, full expansion of both discs allowing for lumen wall apposition, and complete occlusion requiring only a single device. Magnified view (right) shows the shape of the device within the occluded vessel (brackets) with radiopaque markers.

Pulmonary Arteriovenous Malformation

Omar Chohan, D.O.
Vascular Interventional Radiologist
Gates Vascular Institute

A 70-year-old male with a past medical history of atrial fibrillation, DM, and HTN, presented with a PAVM. Because patient was at increased risk for stroke with AF, presence of PAVM doubled his risk for stroke. Elective PAVM embolization was offered with patient choosing to move forward with embolization.
A LOBO-5 occluder was deployed into the feeding artery with excellent accuracy.
Repeat angiography showed immediate occlusion but opacification of PAVM via a small feeding artery within the proximal feeding artery.
A second LOBO-5 was deployed with excellent accuracy and immediate occlusion on follow up angiography and completion angiography revealed no further opacification of the PAVM.
Patient had a good clinical response following the embolization.
The LOBOs were deployed exactly where it was intended to go with no migration.

LOBO is ideal in PAVMs ensuring accurate placement and rapid occlusion with little chance for recanalization given the tight braiding and multiple disc design.

Figure 1: RLL pulmonary angiogram shows PAVM with single feeding vessel and draining vessel.

Figure 2: RLL pulmonary angiography post embolization shows two LOBO-5s (brackets) within the feeding arteries with immediate occlusion and no opacification of the PAVM.

Emergent Uterine Artery Embolization for Postpartum Hemorrhage

Omar Chohan, D.O.
Vascular Interventional Radiologist
Gates Vascular Institute

A 33-year-old female underwent low transverse cesarean section and was found to have a posterior uterine wall rupture which was repaired.
After surgery, a CT scan revealed concern for a uterine artery bleed, and she underwent bilateral uterine artery embolization with Gelfoam. However, after 24 hours she continued to bleed.
She returned to the OR for supracervical hysterectomy and ligation of left uterine artery. However, she continued to pass fresh blood, so patient was brought for emergent bilateral uterine artery embolization.
Arteriography revealed a uterine artery rupture with large volume extravasation into the pelvis.
A LOBO-3 was deployed through a 2.8F PROGREAT microcatheter and provided rapid occlusion with a single device without the need for additional coils or occlusion devices.
LOBO-3 was able to be deployed accurately with a predictable landing zone and no migration. Given time was important, rapid occlusion was desired.
Patient had a good clinical response following embolization with LOBO-3.

LOBO is ideal in emergent bleeding cases where rapid predictable occlusion performance matters. Accurate deployment ensures that the target vessel is treated without non-target embolization.

Figure 1: Selective catheterization and angiography of the left uterine artery showing active bleed.

Figure 2: Still shot of LOBO-3 (bracket) within the left uterine artery just before deployment.

Figure 3: Post embolization arteriography showing LOBO-3 (bracket) in distal left uterine artery successfully occluding the vessel with no further extravasion.

Abdominal Hematoma

Omar Chohan, D.O.
Vascular Interventional Radiologist
Gates Vascular Institute

A 91-year-old male with a past medical history of COPD, CAD, dementia, and DVT on Eliquis presented to the ED for severe abdominal pain and a large bruise over his left anterior abdominal wall.
An abdominal and pelvic CT with contrast showed a large anterior abdominal wall rectus sheath hematoma with active extravasation.
Conservative measures failed to control his symptoms.
The embolization technique utilized a gelfoam slurry to target tiny distal vessels and to ensure distal hemostasis.
Proximally, a permanent occlusion was necessary to prevent recurrent bleeds. The flexibility of the LOBO-3 occluder enabled smooth delivery through the tortuosity of a reverse curve catheter and a 2.8mm left inferior epigastric artery.
Deployment was precise and stable without migration; LOBO-3 provided rapid and complete occlusion of the target artery with a single device.
The patient remained bleed free during hospitalization and left the hospital 3 days following the embolization procedure.

The LOBO occluder provides for smooth trackability and delivery in a tortuous environment. Placement of a single device resulted in rapid and accurate target vessel occlusion without migration. The device generates minimal CT artifact which is of benefit during follow-up imaging.

Figure 1: Contrast enhanced CT of the pelvis shows large anterior abdominal wall rectus sheath hematoma with active extravasation (arrows).

Figure 2: Selective angiogram of the left inferior epigastric artery revealing patent vessel with no active extravasation within the distal or proximal branches.

Figure 3: Spot image demonstrates a microcatheter within the proximal left inferior epigastric artery. Delivery of LOBO-3 can be seen via the proximal and distal radiopaque markers (arrows).

Figure 4: Selective post embolization angiogram revealing complete occlusion of the left inferior epigastric artery following deployment of the LOBO-3 (arrows).

Figure 5: Contrast enhanced CT post embolization shows large anterior abdominal wall rectus sheath hematoma (single arrow) without active extravasation.

Figure 6: LOBO-3 (double arrows) within the left inferior epigastric artery.