RU2551947C1 - Method for transradial endovascular embolisation of uterine arteries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: right and left radial arteries are punctured. The Jadkins right 6F guiding catheter 110 cm long is inserted through a sheath into the descending aorta below the origin of the renal artery mouth. The No-taper angle 4F angiographic catheter 150 cm long is inserted through the sheath via a lumen of the guiding catheter. The angiographic hydrophilic sheath is inserted through the catheter funnel into the distal uterine artery; that is followed by inserting the catheter into the uterine artery and performing the embolisation of the uterine artery through the catheter funnel. Similarly, embolisation is performed on the counterlateral side. In a specific case, the J-ended angiographic hydrophilic sheath 0.018 and 0.035 inches in diameter are used, whereas Biosphere Medical 300-500 mic is used as embolising particles.

EFFECT: using the invention provides the early activation of the patient, prevention of the target arteriospasm, no risk of complications of the transfemoral approach, such as retroperitoneal haematoma, false aneurism, and arteriovenous fistula.

3 cl, 2 ex

Description

The invention relates to medicine, namely to gynecology, obstetrics and endovascular surgery, and can be used in the treatment of uterine fibroids of various localization, uterine bleeding of various etiologies.

Today, problems of uterine fibroids (leiomyoma, fibroma, fibromyoma) in women of childbearing age and bleeding of various etiologies remain relevant both among gynecologists and among obstetricians and endovascular surgeons.

According to modern data, uterine fibroids (MM) is a monoclonal hormone-sensitive proliferate consisting of phenotypically altered smooth muscle cells of the myometrium. MM is detected on average in 80% of women (according to autopsy studies). Clinically, MM appears in 30-35% of women over the age of 35; twice as common in the black race. There are two theories of the origin of the MM progenitor cell. One implies the appearance of a cell defect during the ontogenetic development of the uterus due to a prolonged unstable period of embryonic smooth muscle cells, the second suggests the possibility of damage to the cells in the mature uterus. The fact that, according to autopsy studies, the prevalence of MM reaches 80%, allows us to consider the second theory of the origin of the progenitor cell more plausible.

The main goal of treatment is to eliminate anemic uterine bleeding and other symptoms associated with an increase in the uterus, with the preservation of the organ and the restoration of reproductive function.

To date, many methods have been proposed for the treatment of uterine fibroids with both medical and surgical methods.

Drug treatment is advisable for nodes up to 3 cm in size. Gonadotropin releasing hormone agonists (GnRH) are prescribed - depot forms of 3.75 mg once every 28-30 days, for 6 cycles, starting from the first day of the next menstrual cycle under control Ultrasound 1 time in 3 months. Also use mifepristone or gestrinone 2.5 mg 2 times a week for 3-6 months. If treatment is carried out in perimenopause, natural menopause subsequently occurs. At the reproductive age, the stabilization stage is necessary using modern hormonal contraception (low-dose combined oral contraceptives or the intrauterine hormonal system Mirena ©). Unfortunately, this method does not give positive results in the treatment of large myomatous nodes.

Surgical treatment methods include:

- Radical: hysterectomy with laparotomy, laparoscopic access. The simplest method from the point of view of technical performance. Treatment on the principle of "no organ - no problem." This method is unacceptable for women who want to save the uterus and realize reproductive function. In the modern classification of therapeutic approaches, hysterectomy should be recommended only if there are strict indications. These are: suspicion of uterine sarcoma with rapid growth of fibroids (over 4 weeks in 1 year), the size of MM over 14-16 weeks of pregnancy, the growth of MM in postmenopausal women. A hysterectomy is also indicated for cervical MM, malnutrition in the myomatous node, impaired function of neighboring organs, as well as the inability to perform organ-saving treatment methods or the ineffectiveness of drug treatment for MM and menometorrhagia anemicizing the patient. The choice of surgical access is determined by the size of the uterus and the localization of myomatous nodes. The optimal size for performing a hysterectomy with laparoscopic access is the size of the uterus, not exceeding 11-12 weeks. Limitations on the use of laparoscopic access are uterine size exceeding 16-18 weeks. pregnancy, the presence of low myomatous nodes, especially along the posterior wall of the uterus, or the presence of large intraligamentous myomatous nodes. When choosing surgical access, it is necessary to take into account the concomitant pathology of the ovaries or cervix, the presence and severity of adhesions, somatic diseases. In 30-55% of patients of reproductive age who underwent hysterectomy without appendages, a post-hysterectomy syndrome develops due to a hypoestrogenic state due to a decrease in ovarian blood flow and impaired receptor interactions in the ovary-myometrium-endometrial system. As a treatment for post-hysterectomy syndrome in women of childbearing age, HRT preparations (Femoston 1/5 ©, Divina ©, Klimonorm ©, Cyclo-proginova © and others) or tissue-selective estrogen receptor modulators (Livial ©) should be used. The appointment of HRT drugs for a long course involves monitoring the condition of the mammary glands (ultrasound and mammography up to 2 times a year), monitoring the blood coagulation system and blood lipid spectrum.

- Conservative plastic: traditionally optimal organ-preserving surgery for submucous localization of MM is considered to be transcervical myomectomy using mechanical, electrosurgical and laser surgical methods of removal. The possibility of transcervical myomectomy depends on the size of the node and on its shape. It is possible to remove submucous nodes of type 0 oblong shape and soft consistency up to 10 cm in diameter by mechanical means. Electrosurgical myomectomy is safe with submucous nodes up to 5 cm in diameter. To remove submucous nodes of the 2nd type with a pronounced interstitial component and sizes over 5 cm in diameter, preoperative preparation of GnRH agonists is necessary. After the second injection of the GnRH preparation, myomatous nodes decrease by 35-40% in comparison with the initial sizes. In addition, a number of patients undergo a transition of the 2nd type of submucous node into the 1st, as well as a decrease in blood perfusion in the uterine arteries and the occurrence of drug-induced atrophy of the endometrium, which generally significantly reduces surgical risk and intraoperative blood loss. Along with the positive aspects of the effect of GnRH agonists on the uterus, disadvantages are also known. Adverse is the migration of submucous nodes of the 2nd type intramuscularly, which complicates their search during surgery. In such cases, removal of submucous nodes is not possible. Severe climacteric manifestations associated with estrogen deficiency are also observed in young women.

As a result, electrosurgical transcervical myomectomy is contraindicated if GnRH agonists are ineffective, the size of myomatous nodes is more than 5 cm, the length of the uterine cavity is more than 10 cm, with the combined location of submucous myomatous nodes with nodes of a different location (especially isthmus) and adenomyosis. It is also impractical to conduct electrical resection of myomatous nodes by transcervical access in the presence of a scar after cesarean section or myomectomy, a small and rigid cervix in nulliparous patients.

Considering the issue of organ-preserving surgeries for subserous myomatous nodes, the main criterion for the effectiveness of myomectomy should be the formation of a full scar on the uterus, which should be consistent during subsequent pregnancy. Subserous nodes of types 0 and 1 of small size are not difficult for myomectomy - the method of choice in these cases is laparoscopic access. In cases where the interstitial component of the node is expressed, preoperative preparation of GnRH agonists is indicated to reduce the bed of the node and reduce blood loss at the time of surgery. Compaction and thickening of the pseudocapsule of the myomatous node facilitate its enucleation and allow myomectomy to be less traumatic and bloodless. The bed of the removed subserous site should be carefully sutured. Unfortunately, laparoscopic access does not always allow an adequate comparison of the edges of the wound, often with enucleation of the subserous node an extensive zone of coagulation necrosis is formed, which leads to the formation of defective scar tissue and the presence of a defect in the myometrium layers. A mistake in topographic diagnosis and an overestimation of the technical capabilities in using laparoscopic access is fraught with inconsistency of the scar on the uterus during pregnancy and rupture of the uterus during pregnancy and childbirth. Based on this, clear contraindications to myomectomy by laparoscopic access were determined in patients who want to maintain reproductive function. Laparoscopic myomectomy should not be performed with a large uterus (more than 12 weeks of pregnancy), the presence of multiple interstitial myomatous nodes, a low location (neck-isthmus) of the myomatous node, especially along the back wall, and the total number of myomatous nodes is over 4. These patients undergoing myomectomy is a laparotomy.

The presence of contraindications for performing myomectomy with submucous and subserous myomatous nodes previously left no choice in tactics, and most patients underwent hysterectomy.

- Other methods: high-frequency focused ultrasound (distant thermal coagulation of myomatous nodes); electromyolysis, cryomyolysis (intracavitary destruction of nodes).

- Stable regression. Endoscopic occlusion of the uterine arteries leads to a decrease in the volume of circulating blood in the myometrium, but does not lead to a complete reduction in arterial blood flow in the myomatous nodes. This method is advisable to use before performing endoscopic myomectomy, since the volume of blood loss at the moment of enucleation of the nodes is significantly reduced, and the reduction of myometrium after occlusion causes the allocation of myomatous nodes into the abdominal cavity and a decrease in the size of their bed [V.I. Kulakov, G.M. Savelyeva, I.B. Manukhin. Gynecology - National Guide. GEOTAR - Media - 2009, chap. 24.2, pp. 440, 442-443].

The above methods do not fully provide the main goals of the treatment of uterine fibroids.

With the advent of endovascular methods of treating tumor formations and the possibility of embolization of the uterine arteries (EMA) in patients with MM, a new non-surgical organ-preserving treatment has appeared.

The clinical effectiveness of EMA for MM of various localization consists, first of all, in reducing the size of the uterus and normalizing menstrual function. Menorrhagia has stopped since the EMA, the volume of blood loss during menstruation is reduced by 3-4 times, which leads to a quick recovery of red blood counts. This effect is due to several factors, among which the following are distinguished: a 2-fold decrease in blood perfusion in the uterine artery pool, partial blockage of small radial and basal branches, and complete reduction of arterial blood flow in myomatous nodes. Reducing blood loss, of course, contributes to the restoration of the contractility of the myometrium due to a decrease in the size of the myomatous nodes, as well as the restoration of the anatomical parameters of the uterine cavity after the expulsion or enucleation of submucous nodes. The volume of the uterus and myomatous nodes by the year of observation is reduced by 2.5 and 3 times, respectively. With submucous localization of myomatous nodes, interstitial localization with a central and centripetal growth direction, several outcome options were identified. Spontaneous expulsion of myomatous nodes is possible - myomatous nodes can be released in the form of fragments of necrotic tissue or necrotic detritus. When nodes migrate into the uterine cavity after EMA and the impossibility of their independent expulsion, it is advisable to carry out transcervical myomectomy mechanically or by resection under the control of hysteroscopy or ultrasound.

Possible migration of myomatous nodes intramuscularly. This effect after EMA is also considered favorable, since along with a decrease in the size of the myomatous nodes, the topography of the uterine cavity is restored and the blood loss during menstruation is reduced. The reduction in the size of the bed of myomatous nodes after EMA with their subserous localization allows the formation of a full scar after myomectomy. With large and giant sizes of MM and myomatous nodes in patients of childbearing age, EMA is performed as an independent method or as a stage before laparotomy myomectomy [V.I. Kulakov, G.M. Savelyeva, I.B. Manukhin. Gynecology - National Guide. GEOTAR - Media - 2009, chap. 24.2, pp. 442-443]. Undoubtedly, today EMA is the most effective and relatively safe method in the treatment of MM.

Also, one of the terrible and life-threatening conditions in gynecology and obstetrics is hypo- and atonic bleeding in the early postpartum period, post-shock bleeding, as well as bleeding resulting from the decay of malignant formations of the uterus. Bleeding that occurred in the first 2 hours of the postpartum period is most often due to a violation of the contractile ability of the uterus - its hypo- or atonic state. The term "atony" refers to the condition of the uterus, in which the myometrium completely loses its ability to contract. "Hypotension" is characterized by a decrease in tone and insufficient ability of the myometrium to contract.

The frequency of hypo- and atonic bleeding is 2-4% of the total number of births. Currently, the prevailing percentage of cases of hypotonic bleeding with moderate blood loss. The ratio of the frequency of massive to moderate blood loss is 1:50.

In the absence of the effect of timely treatment (external massage of the uterus, the introduction of uterine contractions, manual examination of the uterine cavity with gentle external and internal massage) with continued bleeding (hemorrhage over 1000 ml), it is necessary to immediately begin glancing. The volume of surgical intervention depends on the state of the puerpera, the degree of impaired contractility of the myometrium and the hemostatic system. Subvaginal amputation of the uterus is performed only in cases where the main cause of bleeding is the hypotonic component, and complex infusion-transfusion therapy stably supports the functions of vital organs and systems. The operation performed without delay allows you to limit blood loss to 1500 ml (30% bcc); timely and adequate replenishment of it with the right choice of anesthesiological aid makes it possible to prevent hemorrhagic shock or its decompensated stages. An alternative to removal of the uterus can be the method of embolization of the uterine arteries - blood flow in the uterus decreases rapidly, which leads to a stop of bleeding [E.K. Aylamazyan. EMERGENCY ASSISTANCE for extreme conditions in obstetric practice. 4th edition, revised and supplemented. St. Petersburg, SpecLit. - 2007, p. 135, 140-141].

However, this method also has several disadvantages: possible hematomas in the area of the femoral artery puncture; arterial spasm; the impossibility of early activation of the patient due to transfemoral access.

The prototype of the invention is a method for embolization of the uterine arteries, which consists in the following:

1. Against the background of sedation, the patient undergoes a puncture of the right or left femoral artery according to Sildenger, an intruder 5 or 6 F is installed in the lumen of the artery.

2. A catheter with a pig-tail tip is carried out to a level slightly lower than the renal arteries and pelvic angiography is performed to clarify the anatomy of the uterine arteries. Particular attention is paid to the ovarian arteries, noting whether the myoma is also supplied with blood from them.

3. A Roberts catheter (COOK) or cobra is inserted into the contralateral uterine artery and selective angiography is performed. Next, the catheter is installed in a transverse portion of the uterine artery. Embolizing particles are introduced into it until the appearance of blood stasis in the vessel. The goal of embolization is to block the branches supplying the myoma, while maintaining blood flow in the main uterine artery.

4. After this, the Roberts catheter is inserted into the ipsilateral artery and the procedure is repeated. This is achieved by performing the Waltmann maneuver. Less commonly, a femoral artery puncture from the opposite side and a cobra catheter should be performed contralaterally, as described in the first case.

5. At the end of the procedure, an overview angiography of the pelvic vessels is performed again in order to evaluate the result of the intervention and detect undetected or opened collaterals from the ovarian arteries.

6. The patient is prescribed intravenously fentanyl and midazolam (dormicum) or seduxen (relanium) to reduce pain after embolization.

7. At the final stage, the intruder is removed from the lumen of the artery, hemostasis is achieved by pressing, or the puncture hole is sutured using suturing devices (Exoseal, Cordis; Perclose, Boston Scintific, etc.) ["Interventional radiology". Guidelines, COOK-2004; p. 29-30].

The disadvantages of this method are: possible hematomas in the area of the puncture of the femoral artery; reflux of embolizing particles into neighboring, non-target vessels; arterial spasm; the impossibility of early activation of the patient due to transfemoral access.

The technical result when using the invention is the early activation of the patient, the prevention of spasm of the target artery, the absence of the risk of complications associated with transfemoral access, such as retroperitoneal hematoma, false aneurysm, arteriovenous fistula.

The specified technical result is achieved by the fact that in the method of embolization of the uterine arteries, including Sylander puncture, panoramic angiography, angiographic hydrophilic conductor under X-ray control, insertion of a catheter through the conductor, selective catheterization of the uterine arteries, introduction of embolizing particles to achieve blood stasis in the artery, control angi , according to the invention, a puncture of the right or left radial artery is performed, then a Jadkins right 6F guide catheter is inserted along the conductor 110 cm into the descending section of the aorta below the outflow of the mouths of the renal arteries, then a 150 cm No-angle angle 4F angiography catheter is inserted through the conductor lumen through the catheter shaft, an angiographic hydrophilic conductor is guided into the distal parts of the uterine artery, and then a catheter is inserted into the uterine artery, embolization of the uterine artery through the catheter shaft is performed, then embolization on the contralateral side is likewise performed. In this case, an angiographic hydrophilic conductor with a “J” tip with a diameter of 0.018 and 0.035 inches is used, and Biosphere Medical 300-500 mic is introduced as embolizing particles.

The proposed method is as follows: the first step is the puncture of the right or left radial artery according to Sildenger, through the lateral channel of the introducer, 1 ml of isoket solution diluted in 10 ml of a 0.9% NaCl solution with 5000 units is injected. heparin and 1 ml of verapamil in order to prevent arterial spasm, then an angiographic hydrophilic conductor with a “J” tip with a diameter of 0.018 and 0.035 inches 260 cm long or more is carried out under X-ray control in the distal uterine artery. The second stage is carried out into the descending aorta below the outflow of the mouth of the renal arteries with a 110 cm long Jadkins right catheter (Cordis) 6. The third stage is a 150-cm long No-taper angle 4F 150 cm (Terumo) with a guide conductor through the lumen of the catheter. An angiographic hydrophilic conductor with a diameter of 0.018 inches and a length of 260 cm with a “J” tip (Terramo) into the distal parts of the uterine artery is passed through the shaft of the catheter. The fourth stage is the embolization of the uterine artery through the catheter shaft with embolization particles of Biosphere Medical 300-500 mic or other embolization means under X-ray control. The final step is to perform control angiography. The presence of stasis of a contrast agent in the lumen of the artery indicates a satisfactory result of the procedure, the balloon is blown off, then embolization is performed on the contralateral side in the manner described above.

Access through the radial artery of the right or left upper limb relieves the patient of undesirable complications associated with transfemoral access (retroperitoneal hematoma, false aneurysm, arteriovenous fistula) and, as a consequence, early activation of the patient.

Use as instruments: guiding catheter, angiographic catheter No-taper angle 4F 150 cm (Terumo) and hydrophilic conductor.

The proposed method was applied in 4 patients with uterine fibroids of different localization.

The invention is illustrated by the following clinical examples.

Example No. 1. Patient S., 33 years old, there were no pregnancies, she was admitted in a planned manner with a diagnosis of Intramural uterine fibroids. Donkey Menorrhagia. Iron deficiency anemia of 1 degree. The patient considers himself 5 years old, when for the first time with a planned ultrasound of the pelvic organs an intramural uterine fibroid with a node size of 10 × 12 mm was detected. During this time, the woman received no treatment.

According to the latest ultrasound of the pelvic organs: Uterus in anteflexio, dimensions: longitudinal 70 mm, anteroposterior - 76 mm, transverse - 80 mm, Contours: uneven, bumpy, clear. The structure of the myometrium is heterogeneous. Echogenicity is mixed. Nodular formations: in the thickness of the posterior wall, a node with a centripetal growth of 44 * 46 mm with peripheral blood flow. The uterine cavity is slightly deformed. M-echo 6 mm. Right ovary, location: typical, dimensions 28 * 13 mm, antral follicles along the periphery of the ovary. Left ovary, location: behind the uterus, dimensions 26 * 14 mm, antral follicles along the periphery of the ovary. There is no free fluid. Conclusion: Intramural uterine fibroids.

The patient's height was 162 cm. A decision was made to perform transradial, endovascular uterine artery embolization.

The first step was a puncture of the right radial artery according to Sylander. Through the side channel of the introducer, 1 ml of isoket solution diluted in 10 ml of 0.9% NaCl solution with 5000 IU of heparin and 1 ml of verapamil was injected to prevent arterial spasm, then an angiographic hydrophilic conductor with a diameter of 0.035 inches with a “J” tip length 260 cm (Terrumo) under X-ray control in the distal sections of the right uterine artery. A second stage 110 cm long Jadkins right 6F (Cordis) catheter was inserted into the descending aorta below the outlet of the renal artery orifice. The third stage was used to insert an angiographic catheter No-taper angle 4F 150 cm (Terrumo) through the lumen of the guide catheter. An angiographic hydrophilic conductor with a diameter of 0.018 inches and a length of 260 cm with a “J” tip (Terrumo) was inserted through the catheter shaft into the distal parts of the uterine artery. The fourth step was an angiographic catheter into the target vessel, the conductor was removed from the catheter, then the uterine artery was embolized through the main shaft of the balloon catheter with Biosphere Medical 300-500 mic embolization particles under X-ray control. The final step was performed control angiography: stasis of the contrast medium in the lumen of the artery. The balloon was blown off, then embolization was performed on the contralateral side as described above. Intraduser and catheter removed; TRBand (Terrumo) hemostatic device placed on the puncture site. The patient 1 hour after the procedure independently moves around the ward, in the morning the hemostatic device TRBand (Terrumo) was removed, the puncture area without features, no signs of hematoma were detected. After 1 day, the patient was discharged in satisfactory condition for outpatient monitoring.

Example No. 2. Patient U., 27 years old, was admitted to the maternity ward with a diagnosis of Pregnancy 39-40 weeks. Head presentation. Donkey Mild gestosis. Mild anemia in pregnant women. Moderate polyhydramnios. Sop. WASP. Obesity II degree. DUZHZH I-II degree, clinical euthyroidism.

This pregnancy in a woman is 2nd, childbirth is 2nd. 1st pregnancy ended in urgent delivery at 38-39 weeks. A live boy was born weighing 3650 g, 54 cm tall. The postpartum period was uneventful. A history of gynecological diseases chronic endometritis against a background of chlamydial infection.

This pregnancy proceeded against the backdrop of the threat of preterm birth in the second and third trimesters, about which examination and treatment were performed twice in a hospital setting.

At 7.30 a.m., bright amniotic fluid flowed. Regular contractions appeared at 8.30 a.m. and at 13.10 a.m. delivery with a living female fetus weighing 3300 g, length 50 cm, with an Apgar score of 7-8 points. The placenta separated on its own. Blood loss during childbirth was 250 ml. The birth canal was examined - no injuries.

In the early postpartum period, abundant bloody discharge of about 300 ml appeared from the genital tract. The clots are friable, the amount of discharge increases. Diagnosed with Early postpartum hypotonic bleeding. With 500 ml blood loss and ongoing bleeding during infusion therapy, a manual examination of the uterine cavity was performed, parietal clots were removed, the integrity of the walls of the uterus was not compromised, the uterus was massaged with a fist, and uterotonics were infused. The uterus remained soft, at the level of the navel, the bleeding did not stop. The volume of blood loss reached 650 ml. It was decided to perform transradial, endovascular embolization of the uterine arteries.

The first step was a puncture of the right radial artery according to Sylander. Through the side channel of the introducer, 1 ml of isoket solution diluted in 10 ml of 0.9% NaCl solution with 5000 IU of heparin and 1 ml of verapamil was injected to prevent arterial spasm, then an angiographic hydrophilic conductor with a diameter of 0.035 inches with a “J” tip length 260 cm (Terrumo) under X-ray control in the distal sections of the right uterine artery. A Jadkins right 6F (Cordis) guide catheter 110 cm long was inserted into the descending aorta section below the outlet of the kidneys of the renal arteries. The third step was the angiographic catheter NoFaper angle 4F 150 cm (Terumo) was introduced through the lumen of the guide catheter. An angiographic hydrophilic conductor with a diameter of 0.018 inches and a length of 260 cm with a “J” tip (Terrumo) was inserted through the catheter shaft into the distal parts of the uterine artery. The fourth step was an angiographic catheter into the target vessel, the conductor was removed from the catheter, then the uterine artery was embolized through the main shaft of the balloon catheter with Biosphere Medical 300-500 mic embolization particles under X-ray control. The final step was performed control angiography: stasis of the contrast medium in the lumen of the artery. The balloon was blown off, then embolization was performed on the contralateral side as described above. Intraduser and catheter removed; TRBand (Terrumo) hemostatic device placed on the puncture site. The patient was transferred to the intensive care unit for further dynamic observation and treatment; in the morning, the TRBand (Terrumo) hemostatic device was removed, the puncture area was without features, and there were no signs of a hematoma. On the 10th day the patient was discharged in satisfactory condition for outpatient monitoring.

Claims (3)

1. A method for embolization of the uterine arteries, including Sildenger puncture, panoramic angiography, angiographic hydrophilic conductor under X-ray control, insertion of a catheter through the catheter, selective catheterization of the uterine arteries, introduction of embolizing particles to achieve blood stasis in the arteries, control angiography, characterized in that puncture of the right or left radial artery, then a Jadkins right 6F guide catheter 110 cm long is inserted along the conductor into the descending aorta below the outlet of the mouth in the renal arteries, after which a 150 cm long angiographic catheter No-taper angle 4F is inserted through the conductor lumen, an angiographic hydrophilic conductor is passed through the catheter shaft into the distal parts of the uterine artery, after which a catheter is inserted into the uterine artery, uterine artery is embolized through the catheter shaft, then embolization on the contralateral side is likewise performed. 2. The method according to p. 1, characterized in that they use an angiographic hydrophilic conductor with a "J" tip with a diameter of 0.018 and 0.035 inches. 3. The method according to p. 1, including the introduction of embolizing particles of Biosphere Medical 300-500 mic.