A new twist on the Waltman loop for uterine fibroid embolization

Ipsilateral Uterine Artery Access Through Unilateral Transfemoral Approach Using Simple-Curve Catheter

Uterine artery embolization (UAE) is a technique for management of various obstetrical and gynecological problems. Transfemoral approach (TFA) is preferred which can be unilateral or bilateral; however, unilateral puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture. UAE through unilateral TFA is possible with use of reverse loop catheters (Roberts uterine catheter [RUC] or Gandras catheter) to access ipsilateral uterine artery. Other way of cannulating the ipsilateral uterine artery is by maneuvering catheters to form Waltman's loop/Simmon's reverse loop. With advent of RUC, unilateral TFA became standard of care. In the recent past, RUC was retracted from Indian market and its nonavailability had mandated use of either bilateral TFA or use of catheters and techniques used in the past for unilateral TFA. Herein, we describe a technique of doing UAE by unilateral TFA using simple gentle curve catheter (Picard) by making a reverse curve loop.

Postpartum haemorrhage due to genital tract injury after vaginal delivery: safety and efficacy of transcatheter arterial embolisation

OBJECTIVES

To evaluate the safety and efficacy of transcatheter arterial embolisation (TAE) managing postpartum haemorrhage associated with genital tract injury (PPH-GTI) and to determine the factors associated with clinical outcomes.

METHODS

From 2002 to 2017, a retrospective analysis was performed in 60 patients (mean 31.5 years) undergoing TAE for PPH-GTI. Information regarding clinical data, angiography and embolisation details, and clinical outcomes was obtained. Univariate analyses were performed to determine the factors related to clinical outcomes.

RESULTS

Technical and clinical success was achieved in 98% and 88%, respectively. Bleeding foci were observed on angiography in 56 patients (93%). The major bleeding artery was the vaginal artery (32%, 24/74), followed by the uterine artery (cervicovaginal branch) (n = 18), internal pudendal artery (n = 13), cervical artery (n = 9), inferior mesenteric artery (n = 4) and external pudendal artery (n = 3). Embolic agents were gelatin sponge particles (n = 23), gelatin sponge with permanent embolic agents (microcoils, n-butyl cyanoacrylate) (n = 34) and permanent embolic agents only (n = 3). In seven patients, bleeding control failed and was managed by repeat TAE (n = 5) or surgery (n = 2) and with eventual bleeding control in all of these patients. Univariate analysis showed that paravaginal haematoma, massive transfusion and long hospital stay were related to clinical failure. During the mean follow-up period of 33.1 months, regular menstruation resumed in 95.2% (40/42) and 14 of them became pregnant.

CONCLUSIONS

TAE is safe and effective for treating PPH-GTI. Massive transfusion, paravaginal haematoma and long hospital stay were related to the failure of bleeding control.

KEY POINTS

• PPH-GTI had a high detection rate of active bleeding foci on angiography. • Besides vaginal artery, inferior mesenteric and external pudendal arteries were notable bleeding foci. • Permanent embolic agents were used more than only gelatin sponge particles. • Paravaginal haematoma and massive transfusion were related to clinical failure. • TAE for PPH-GTI was safe and effective with preservation of menstrual cycles.

Interventional radiology: a half century of innovation

The evolution of modern interventional radiology began over half century ago with a simple question. Was it possible to use the same diagnostic imaging tools that had revolutionized the practice of medicine to guide the real-time treatment of disease? This disruptive concept led to rapid treatment advances in every organ system of the body. It became clear that by utilizing imaging some patients could undergo targeted procedures, eliminating the need for major surgery, while others could undergo procedures for previously unsolvable problems. The breadth of these changes now encompasses all of medicine and has forever changed the way we think about disease. In this brief review article, major advances in the field, as chronicled in the pages of Radiology, will be described.

Use of the 4F Rösch Inferior Mesenteric Catheter in Embolization Procedures in the Pelvis: A Review of 300 Cases

The aim of this study is to evaluate the use of a 4F Rösch inferior mesenteric (RIM) catheter for pelvic embolization procedures. Between October 2000 and January 2006, 364 patients (357 female, 7 male; age: 23-67 years) underwent embolization of various pathologies [uterine fibroids (n = 324), pure adenomyosis of the uterus (n = 19), postpartum hemorrhage (n =1), traumatic or postoperative hemorrhage (n = 9), bleeding related to cervical cancer (n =7), AV malformation of the uterus (n = 2) and high-flow priapism (n = 2)] at a single institution. In all cases, bilateral catheterization was primarily attempted with the use of a 4F hook-shaped braided endhole catheter (Rösch-Inferior-Mesenteric, RIM-Catheter, Cordis, Miami, FL). Frequency of initial failure to catheterize the vascular territory of interest and carry out the embolization were recorded and the types of difficulty encountered were noted. Catheterization of the main stem of the vessel territory of interest with the use of a unilateral femoral approach and the 4F RIM catheter was successful in 334/364 (91.8%) the embolization cases. Bilateral catheterization of the internal iliac arteries using a single common femoral artery access and the 4F RIM catheter was achieved in 322/364 (88.5%) patients. In 12/364 (3.3%) patients, a contralateral puncture was performed and the same 4F catheter was used. In 28/364 (7.7%) cases the 4F RIM catheter was exchanged for a catheter with a cobra-shaped or sidewinder configuration. The 4F RIM catheter is a simple and valuable alternative to catheters and techniques commonly employed for pelvic artery embolization.

Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status

Uterine artery embolization (UAE) is increasingly being used as an alternative treatment to hysterectomy for symptomatic fibroids. Symptoms of pelvic pressure, urinary frequency and menorrhagia are controlled in 73-98% of patients who undergo UAE. At the 1-year follow-up, the uterus may shrink by up to 55% but re-growth of fibroid may however occur. The rate of major complications and amenorrhoea following this procedure is low, ranging in most series from 1 to 3.5% and 1 to 7%, respectively. Nevertheless, the rate of amenorrhoea in women over 45 seems to be higher. In order to completely block the arterial supply to the fibroid, UAE is typically performed in both uterine arteries. Different embolic agents are used such as polyvinyl alcohol, gelfoam and more recently gelatine tris-acryl microspheres. After UAE, perfusion of the uterus is maintained. Uterine function is therefore conserved and although women who become pregnant after UAE seem to be at risk for malpresentation, pre-term birth, cesarean delivery and postpartum hemorrhage, successful pregnancies after UAE have been reported in some series. A major technical problem with UAE remains the possible presence of fibroid blood supply from other sources, such as the ovarian arteries or other pelvic branches, which can lead to failure of the procedure. In conclusion, although randomized trials are still underway, UAE appears a good option for those patients who whish to conserve their fertility or when surgery is contra-indicated. However, to evaluate the long-term effects of UAE longer follow up is required.

Uterine artery embolisation for uterine fibroids using a 4F Rosch inferior mesenteric catheter

PURPOSE

To evaluate in a prospective study the use of a 4F Rosch inferior mesenteric (RIM) catheter for uterine artery embolisation (UAE).

MATERIALS AND METHODS

UAE was performed in 72 women over a 37-month period. A 4F RIM braided J-curve 65-cm catheter was used in combination with an angled hydrophilic 150 cm, 0.035" flexible tip guide-wire to catheterise the horizontal portion of both uterine arteries (UA) from a right common femoral artery (CFA) approach. Technical success was defined as successful catheterisation and embolisation of both uterine arteries. Fluorosocpic and procedure times were recorded.

RESULTS

Mean subject age=43.7 years (range=25-57 years). Technical success was 98.6% (n=71/72). A single approach via the right CFA was used in 88.9% (n=64/72) and a bilateral CFA approach in 11.1% (n=8/72). Bilateral uterine artery catheterisation using a single 4F RIM catheter via the right CFA approach was successful in 79.2% (n=57/72). Microcatheters were used in 2.8% of patients (n=2/72). Mean fluoroscopic time=13.6+/-5.3 min (mean+/-SD). Mean procedure time=44.2+/-16.5 min.

CONCLUSION

High technical success rate for UAE is possible using a single 4F RIM catheter via a unilateral right CFA approach, which obviates the need for Waltman loop formation, reversed curve catheters and complex suture-catheter arrangements.

II. Uterine fibroid embolization: technical aspects

Successful superselective catheterization of the uterine artery requires familiarity with female pelvic arterial anatomy, knowledge of effective catheter and guidewire combinations, and a few tricks. A learning curve can be expected for each of these elements, although it is assumed that the operator will already have experience in basic catheter techniques. Safe transcatheter delivery, understanding of embolization end points, and avoidance of nontarget embolization are essential. Equally important are knowledge of the properties of the embolic agents currently available and their indications for use. Uterine fibroid embolization unavoidably results in radiation exposure to the uterus and ovaries, and adherence to meticulous fluoroscopic technique is crucial to keep the absorbed dose as low as possible.