Are fibroid and bony pelvis characteristics associated with urinary and pelvic symptom severity?

BACKGROUND

Urinary and pelvic floor symptoms often are attributed to size and location of uterine fibroid tumors. However, direct supporting evidence that links increased size to worsening symptoms is scant and limited to ultrasound evaluation of fibroid tumors. Because management of fibroid tumors is targeted towards symptomatic relief, the identification of fibroid and pelvic characteristics that are associated with worse symptoms is vital to the optimization of therapies and prevention needless interventions.

OBJECTIVE

We examined the correlation between urinary, pelvic floor and fibroid symptoms, and fibroid size and location using precise uterine fibroid and bony pelvis characteristics that were obtained from magnetic resonance imaging.

STUDY DESIGN

A retrospective review (2013-2017) of a multidisciplinary fibroid clinic identified 338 women who had been examined via pelvic magnetic resonance imaging, Pelvic Floor Distress Inventory questionnaire (score 0-300), and a Uterine Fibroid Symptoms questionnaire (score 1-100). Multiple linear regression analysis was used to assess the influence of clinical factors and magnetic resonance imaging findings on scaled Pelvic Floor Distress Inventory and Uterine Fibroid Symptoms scores. Data were analyzed with statistical software.

RESULTS

Our cohort of 338 women had a median Pelvic Floor Distress Inventory of 72.7 (interquartile range, 41-112.3). Increased Pelvic Floor Distress Inventory score was associated with clinical factors of higher body mass index (P<.001), noncommercial insurance (P<.001), increased parity (P=.001), and a history of incontinence surgery (P=.003). Uterine volume, dominant fibroid volume, dimension and location, and fibroid tumor location relative to the bony pelvis structure did not reach significance when compared with pelvic floor symptom severity. The mean Uterine Fibroid Symptoms score was 52.0 (standard deviation, 23.5). An increased Uterine Fibroid Symptoms score was associated with dominant submucosal fibroid tumors (P=.011), body mass index (P<.0016), and a clinical history of anemia (P<.001) or any hormonal treatment for fibroid tumors (P=.009).

CONCLUSION

Contrary to common belief, in this cohort of women who sought fibroid care, size and position of fibroid tumors or uterus were not associated with pelvic floor symptom severity. Whereas, bleeding symptom severity was associated with dominant submucosal fibroid tumor and previous hormonal treatment. Careful attention to clinical factors such as body mass index and medical history is recommended when pelvic floor symptoms are evaluated in women with uterine fibroid tumors.

Treatment of Low-Flow Vascular Malformations of the Extremities Using MR-Guided High Intensity Focused Ultrasound: Preliminary Experience

Five patients with painful vascular malformations of the extremities that were refractory to standard treatment and were confirmed as low-flow malformations on dynamic contrast-enhanced magnetic resonance (MR) imaging were treated with MR imaging-guided high intensity focused ultrasound. Daily maximum numeric rating scale scores for pain improved from 8.4 ± 1.5 to 1.6 ± 2.2 (P = .004) at a median follow-up of 9 months (range, 4-36 mo). The size of the vascular malformations decreased on follow-up MR imaging (median enhancing volume, 8.2 mL [0.7-10.1 mL] before treatment; 0 mL [0-2.3 mL] after treatment; P = .018) at a median follow-up of 5 months (range, 3-36 mo). No complications occurred.

Optimal imaging surveillance schedules after liver-directed therapy for hepatocellular carcinoma

PURPOSE

To optimize surveillance schedules for the detection of recurrent hepatocellular carcinoma (HCC) after liver-directed therapy.

MATERIALS AND METHODS

New methods have emerged that allow quantitative analysis and optimization of surveillance schedules for diseases with substantial rates of recurrence such as HCC. These methods were applied to 1,766 consecutive chemoembolization, radioembolization, and radiofrequency ablation procedures performed on 910 patients between 2006 and 2011. Computed tomography or magnetic resonance imaging performed just before repeat therapy was set as the time of "recurrence," which included residual and locally recurrent tumor as well as new liver tumors. Time-to-recurrence distribution was estimated by Kaplan-Meier method. Average diagnostic delay (time between recurrence and detection) was calculated for each proposed surveillance schedule using the time-to-recurrence distribution. An optimized surveillance schedule could then be derived to minimize the average diagnostic delay.

RESULTS

Recurrence is 6.5 times more likely in the first year after treatment than in the second. Therefore, screening should be much more frequent in the first year. For eight time points in the first 2 years of follow-up, the optimal schedule is 2, 4, 6, 8, 11, 14, 18, and 24 months. This schedule reduces diagnostic delay compared with published schedules and is cost-effective.

CONCLUSIONS

The calculated optimal surveillance schedules include shorter-interval follow-up when there is a higher probability of recurrence and longer-interval follow-up when there is a lower probability. Cost can be optimized for a specified acceptable diagnostic delay or diagnostic delay can be optimized within a specified acceptable cost.

Pulmonary hypertensive crisis following ethanol sclerotherapy for a complex vascular malformation

Anhydrous ethanol is a commonly used sclerotic agent for treating vascular malformations. We describe the case of a full-term 15-day-old female with a complex venolymphatic malformation involving the face and orbit. During treatment of the lesion with ethanol sclerotherapy, she suffered acute pulmonary hypertensive crisis. We discuss the pathophysiology of pulmonary hypertension related to ethanol sclerotherapy, and propose that hemolysis plays a significant role. Recommendations for evaluation, monitoring and management of this complication are also discussed.

Applying a structured innovation process to interventional radiology: a single-center experience

PURPOSE

To determine the feasibility and efficacy of applying an established innovation process to an active academic interventional radiology (IR) practice.

MATERIALS AND METHODS

The Stanford Biodesign Medical Technology Innovation Process was used as the innovation template. Over a 4-month period, seven IR faculty and four IR fellow physicians recorded observations. These observations were converted into need statements. One particular need relating to gastrostomy tubes was diligently screened and was the subject of a single formal brainstorming session.

RESULTS

Investigators collected 82 observations, 34 by faculty and 48 by fellows. The categories that generated the most observations were enteral feeding (n = 9, 11%), biopsy (n = 8, 10%), chest tubes (n = 6, 7%), chemoembolization and radioembolization (n = 6, 7%), and biliary interventions (n = 5, 6%). The output from the screening on the gastrostomy tube need was a specification sheet that served as a guidance document for the subsequent brainstorming session. The brainstorming session produced 10 concepts under three separate categories.

CONCLUSIONS

This formalized innovation process generated numerous observations and ultimately 10 concepts to potentially to solve a significant clinical need, suggesting that a structured process can help guide an IR practice interested in medical innovation.

Consolidation of hepatic arterial inflow by embolization of variant hepatic arteries in preparation for yttrium-90 radioembolization

PURPOSE

Before yttrium-90 ((90)Y) radioembolization administration, the authors consolidated arterial inflow by embolizing variant hepatic arteries (HAs) to make microsphere delivery simpler and safer. The present study reviews the technical and clinical success of these consolidation procedures.

MATERIALS AND METHODS

Preparatory and treatment angiograms were retrospectively analyzed for 201 patients. Variant HAs were coil-embolized during preparatory angiography to simplify arterial anatomy. Collateral arterial perfusion of territories previously supplied by variant HAs was evaluated by digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) scintigraphy, and by follow-up evaluation of regional tumor response.

RESULTS

A total of 47 variant HAs were embolized in 43 patients. After embolization of variant HAs, cross-perfusion into the embolized territory was depicted by DSA and by C-arm CT in 100% of patients and by (99m)Tc-MAA scintigraphy in 92.7%. Uniform progressive disease prevented evaluation in 33% of patients, but regional tumor response in patients who responded supported successful delivery of microspheres to the embolized territories in 95.5% of evaluable patients.

CONCLUSIONS

Embolization of variant HAs for consolidation of hepatic supply in preparation for (90)Y radioembolization promotes treatment of affected territories via intrahepatic collateral channels.

Percutaneous cholecystostomy for acute cholecystitis: ten-year experience

PURPOSE

To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.

MATERIALS AND METHODS

A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.

RESULTS

Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).

CONCLUSIONS

Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

Development of new hepaticoenteric collateral pathways after hepatic arterial skeletonization in preparation for yttrium-90 radioembolization

PURPOSE

Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization.

MATERIALS AND METHODS

One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization.

RESULTS

Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038).

CONCLUSIONS

Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.

MR volumetric measurements of the myomatous uterus: improved reliability of stereology over linear measurements

RATIONALE AND OBJECTIVES

Stereology is a simple, fast method for object segmentation that involves counting the number of intersections of a randomly positioned grid over an object. The objectives of this study were to determine observer reliability in making stereologic- and ellipsoid-based measurements of uterine and leiomyoma volumes and to test the agreement between these two methods of measurement.

MATERIALS AND METHODS

Two observers made uterine and dominant leiomyoma volume measurements on MR images in 30 patients using stereology and the popular ellipsoid-based technique. Stereologic volume measurements were made from high-resolution T2 images in two perpendicular planes (axial and sagittal). Ellipsoid volume was calculated by multiplying the maximal sagittal, anteroposterior, and transverse dimensions by pi/6. For these measurements, interobserver reliability was tested with paired t-tests and percent differences were determined. A mean stereologic volume and a mean ellipsoid volume were determined and tested for agreement with a paired t-test. Percent differences were also calculated.

RESULTS

Stereologic measurements demonstrated excellent interobserver reliability with 0.3% difference in mean uterine volumes (P = .69) and 0.3% difference (P = .81) in mean leiomyoma volumes. The ellipsoid method resulted in poorer interobserver reliability with 7% difference (P = .01) in mean uterine volumes and 4% difference (p = .24) in mean leiomyoma volumes. The ellipsoid method also significantly overestimated uterine volumes by 14% (P < .01) compared with stereology.

CONCLUSION

Stereology provided high interobserver reliability for leiomyoma and overall uterine volume measurements and was more reliable than the ellipsoid method, which uses linear measurements. Stereology appears well suited when precise volume measurements are desired for assessing response to uterine arterial embolization treatments.

Ureteric embolization with stainless-steel coils for managing refractory lower urinary tract fistula: a 12-year experience

OBJECTIVE

To report our 12-year experience with radiological treatment (ureteric embolization) for refractory urinary fistula, as malignancy, radiation therapy, and/or chronic inflammation increase the risk of lower urinary tract fistula after surgical urinary diversion, which can lead to significant morbidity, and for patients who are not surgical candidates permanent nephrostomy drainage and ureteric embolization offer an alternative form of urinary diversion.

PATIENTS AND METHODS

We retrospectively reviewed patients who had ureteric occlusion for refractory urinary fistula at our institution between 1993 and 2005. Stainless-steel coils, with or without gelatine sponge, were placed antegradely through a percutaneous nephrostomy tract. Patients were then managed by long-term nephrostomy drainage until death or definitive reconstructive surgery.

RESULTS

In all, 29 patients (23 women and six men; mean age 59 years, sd 16) were identified who had urinary fistulae that were refractory to nephrostomy drainage alone. One patient had a history of severe perineal trauma and the remaining 28 had a history of cancer. Seventeen fistulae occurred in the setting of previous surgery, 20 patients had received adjunctive pelvic irradiation and 11 had had chemotherapy. In all, 52 ureters were embolized; occlusion was successful in all cases, with complete or near-complete (<1 pad/day) dryness within 3 days. No repeat embolization was required and there were no significant complications. Two patients were lost to follow-up. Three patients had definitive urinary diversion surgery and currently are well. One patient is alive and living with nephrostomy tubes; 23 patients have died.

CONCLUSION

Ureteric embolization is a viable option for managing complex lower urinary tract fistulae in patients with a poor performance status. It can be used as definitive management in patients with a limited life-expectancy or as a temporary measure in those for whom another management plan is anticipated.

A Prospective Comparison of the Impact of Uterine Artery Embolization, Myomectomy, and Hysterectomy on Ovarian Function

PURPOSE

To prospectively compare uterine artery embolization (UAE) versus myomectomy and hysterectomy with regard to ovarian function as measured by postprocedure follicle-stimulating hormone (FSH) levels and symptoms.

MATERIALS AND METHODS

Fifty-five patients were prospectively enrolled in the study: 33 patients who underwent UAE, seven who underwent myomectomy, and 15 who underwent hysterectomy. Patients had serum FSH and estradiol levels measured on the third day of the menstrual cycle before their procedure and at regular follow-up visits for as long as 6 months. At these intervals, patients were also surveyed regarding menopausal symptoms.

RESULTS

Although a mild transient increase in mean FSH level after UAE was noted at 3 months, there were no statistically significant differences among the three groups in mean FSH levels at 1 month, 3 months, or 6 months of follow-up. Menopausal symptoms arose in the UAE and hysterectomy groups, but there was no statistically significant difference or permanent effect in either group.

CONCLUSION

There is no significant difference in impact on ovarian function after UAE, hysterectomy, or myomectomy at follow-up for a maximum of 6 months.

Comparison of Adjunctive Use of Rofecoxib versus Ibuprofen in the Management of Postoperative Pain after Uterine Artery Embolization

PURPOSE

The primary purpose of the present study was to compare the antiinflammatory effectiveness of rofecoxib with that of ibuprofen in the first 5 days after uterine artery embolization (UAE). The secondary aim was to compare pain levels and narcotic use among patients treated with different embolic agents.

MATERIALS AND METHODS

From July 2003 to June 2004, 68 UAE procedures were performed by one of the authors (D.M.H.). Of this group, 50 women agreed to participate in this study. Exclusion criteria were limited to contraindication to either drug or current steroid or nonsteroidal antiinflammatory drug use. In a randomized, double-blinded fashion, patients received a numbered pill box that contained one of the two agents and its placebo counterpart. Four times per day for 5 days, patients recorded their level of pain on a visual analog scale and the amount of narcotic analgesic drug needed at that time. Score sheets were returned by mail after completion. During the course of the study, three embolic agents (Gold Embospheres, Contour SE particles, and Embospheres) were used in succession, with similar numbers of patients in each group.

RESULTS

Four patients were excluded from analysis: two who were readmitted to the hospital for treatment of pain (one treated with each antiinflammatory medication) and two who failed to complete their score sheets. Subject demographics were very similar with respect to antiinflammatory drug treatment and embolic agent, except that the average age of patients in the Embosphere group was 6 years older than in the Embosphere Gold and Contour SE groups (P= .02). There was no difference in the pain level and narcotic drug intake between the two drug arms, but among embolic agents, the Embosphere Gold group tended to have a higher overall average pain score (P = .12), and the two patients readmitted were in this group. Patients in the Contour SE group tended to use a lower amount of narcotic drug than those in the other two embolic agent groups (P = .09).

CONCLUSIONS

There was no difference between rofecoxib and ibuprofen with respect to postprocedural pain or narcotic use after UAE. Embolic agent appeared to have a greater impact, with patients in the Embosphere Gold group reporting higher pain scores and those in the Contour SE group requiring a lower amount of narcotic drug than those in the Embosphere Gold or Embosphere groups.

Measurement of Blood Flow Before and After Embolization with Use of Fluorescent Microspheres in an Animal Model

PURPOSE

Catheter-directed embolization has become a widespread technique for the treatment of benign and malignant neoplasms. The mechanism whereby embolization leads to selective atrophy of these neoplasms is largely speculative. As a potential model for the large regional perfusion differences between normal and neoplastic tissues, renal perfusion was studied before and after catheter-directed embolization. The working hypothesis was that embolization would create measurable changes in blood flow in the renal cortex and medulla.

MATERIALS AND METHODS

Microspheres (l0 microm in diameter) containing a series of different fluorophores were injected into the arterial system before and after the renal arteries were embolized with a series of larger (100-300 microm) particulate embolic agents. The distribution of the microspheres in the renal cortex, renal medulla, and liver was analyzed by fluorescence microscopy as well as by extraction of the fluorophores.

RESULTS

The distribution of the fluorescent microspheres was readily assessed by fluorescence microscopy or extraction of the fluorophores. Before embolization, the renal cortex received approximately three times more flow than the medulla. After embolization, perfusion of the renal cortex and medulla decreased in parallel.

CONCLUSIONS

Fluorescent microspheres are a powerful tool for measuring the changes in flow that occur after catheter-directed embolization. The fact that parallel decreases in flow were found in the renal cortex and medulla indicates that the distribution of each embolic agent was flow-directed. These results might provide insight into the mechanism of tumor atrophy after uterine artery embolization or hepatic chemoembolization.

Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata

Uterine artery embolization (UAE) is assuming an important role in the treatment of women with symptomatic uterine leiomyomata worldwide. The following guidelines, which have been jointly published with the Society of Interventional Radiology in the Journal of Vascular and Interventional Radiology, are intended to ensure the safe practice of UAE by identifying the elements of appropriate patient selection, anticipated outcomes, and recognition of possible complications and their timely address.

Type II endoleak after endovascular abdominal aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective

OBJECTIVES

The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more.

METHODS

Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (>or=6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery.

RESULTS

Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 +/- 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 +/- 8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was US dollars 6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months.

CONCLUSIONS

Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.

Pregnancy outcomes after fallopian tube recanalization: oil-based versus water-soluble contrast agents

PURPOSE

To determine the pregnancy outcomes in patients undergoing fallopian tube recanalization (FTR) with use of oil-based versus water-soluble contrast agents.

MATERIALS AND METHODS

Ninety-three patients with unilateral or bilateral proximal tubal occlusion confirmed by hysterosalpingography or laparoscopy underwent FTR with use of water-soluble contrast material alone (n = 50) or also had an oil-based agent injected into each tube after recanalization (n = 43). Pregnancy rates and outcomes of the two groups were studied retrospectively.

RESULTS

With respect to differences between groups, only the body mass index proved to be a significant predictor (oil, 28.4; water, 24.7; P =.008). Mean age, duration of infertility, type of infertility, and initial diagnosis were comparable. There was a weak trend toward a higher pregnancy rate in the oil-based contrast material group, but it was not significant (P =.64). The average time to pregnancy was 4.4 months with use of oil-based contrast material, compared to 7.7 months with use of only water-soluble contrast material (P =.03).

CONCLUSION

The use of an oil-based agent had little effect on the rate of conception, but time to conception was reduced by more than 3 months.

Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy

PURPOSE

To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis.

MATERIALS AND METHODS

Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded.

RESULTS

Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006).

CONCLUSION

The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

Angiographic follow-up after suture-mediated femoral artery closure

PURPOSE

Percutaneous closure devices are used in as many as 30% of all endovascular studies. Despite widespread use of these devices, only limited imaging has been performed after percutaneous closure. In this study, arteriograms of patients who had undergone suture-mediated closure with the Perclose device were reviewed.

MATERIALS AND METHODS

Between June 1998 and November 2001, 31 patients who had previously undergone closure with use of the Perclose device at our institution returned for additional angiographic procedures. Twenty-one patients underwent closure with use of the Perclose device after embolization, including hepatic artery chemoembolization (n = 18), treatment of hypervascular sacral metastases (n = 2), and bronchial artery embolization (n = 1). Nineteen of these patients had thrombocytopenia. Ten patients underwent closure with use of the Perclose device after diagnosis and treatment of peripheral vascular disease.

RESULTS

Of 31 patients, 28 had normal follow-up studies, including one patient who underwent four previous closures. These 28 patients all had normal femoral artery caliber at initial angiography and a platelet count of more than 18,000/mm(3). Two patients with preexisting atherosclerotic change had progression of disease at the puncture site and a third with severe thrombocytopenia developed a small asymptomatic posterolateral pseudoaneurysm.

CONCLUSION

In patients with normal femoral arteries, the long-term effects of closure with use of the Perclose device, even performed multiple times, appears to be minimal.

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.

I. Uterine fibroid embolization: preprocedure assessment

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

VI. Uterine fibroid embolization: developing a clinical service

Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.

IV. Uterine fibroid embolization: follow-up

Patients generally notice some relief of both menorrhagia and mass-effect symptoms during the first few weeks after uterine fibroid embolization (UFE). Shrinkage of the fibroids continues to take place over several months, peaking somewhere between 3 and 6 months, with measurable shrinkage sometimes noted for up to 1 year. The timing of follow-up visits is intended to coincide with the time course of improvement so that diagnostic imaging and intervention can be performed if symptoms worsen or relief does not appear to be on schedule. The amount of shrinkage of fibroids correlates neither with the intensity of immediate postprocedure symptoms or the degree of symptom relief. Affected fibroids undergo hyaline degeneration, a process in which the hard, cellular tumor is replaced by softer, acellular material. A nationwide registry has been constructed for the accumulation of procedural and follow-up data so that success and complication rates can be accurately determined and long-term issues about the durability of UFE and possible side effects can be addressed.

V. Uterine fibroid embolization: management of complications

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

III. Uterine fibroid embolization: pain management

Conscious sedation and analgesia are integral components of successful uterine fibroid embolization (UFE), both in providing comfort to the anxious patient undergoing an elective procedure and for providing relief of the severe pelvic pain, cramps, and nausea that may result from acute uterine ischemia and the postembolization syndrome that may follow. The agents used are typically those with which interventional radiologists already have extensive experience in the performance of a variety of invasive procedures. Immediate postprocedure care benefits greatly from the use of narcotic delivered via PCA (patient-controlled analgesia) pump. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also particularly useful for treating the pain and cramping caused by UFE and help reduce the amount of narcotic necessary for pain relief during the recovery period. Detailed instructions for the first week of convalescence are necessary to insure comfort and avoid complications.

Use of aortic cuffs to exclude iliac artery aneurysms during AneuRx stent-graft placement: initial experience

PURPOSE

As many as 39% of patients who undergo aortic endografting for abdominal aortic aneurysm disease will have ectasia of the iliac arteries that will require intervention. Coil embolization of the internal iliac artery and extension of the graft to the external iliac artery is one solution to this problem. However, 19%-41% of these patients experience buttock claudication, which may be permanent, after unilateral embolization. The authors examined an alternative: the use of larger-sized aortic cuffs to seal the iliac limb. Outcomes and short-term results are presented in this article.

MATERIALS AND METHODS

From October 1999 to August 2000, 144 AneuRx stent-grafts were placed at the authors' institution. Among the population receiving stent-grafts, 14 patients had 15 aortic cuffs placed across the distal iliac graft limbs to seal them and preserve flow to the internal iliac artery. One patient had bilateral cuffs placed. Five patients had embolization of the contralateral internal iliac artery because of bilateral disease. Patients were followed with computed tomography (CT) at 1, 6, and 12 months to evaluate for endoleaks.

RESULTS

One- and 6-month endoleak rates, determined from only those patients with follow-up CT, were 0% and 10%, respectively. One type II endoleak was first discovered 9 months after graft placement. It sealed spontaneously at 15-month follow-up. One patient among the five who had internal iliac artery embolization had claudication. Mean CT follow-up was 7.8 months (range, 1-15). One patient declined CT but was alive and well 11 months after endografting. One patient moved across the country and declined follow-up.

CONCLUSION

Placement of aortic cuffs in dilated iliac arteries can preserve flow to the ipsilateral internal iliac artery and provide an adequate seal. Additionally, the option of later treatment is maintained. Patients with bilateral iliac ectasia can undergo stent-graft placement without bilateral internal iliac artery embolization. Longer-term follow-up in larger numbers of patients will be important to determine the ultimate durability of this technique.

Endovascular abdominal aortic aneurysm repair in 144 patients: correlation of aneurysm size, proximal aortic neck length, and procedure-related complications

PURPOSE

During endovascular abdominal aortic aneurysm (AAA) repair, larger aneurysms often present formidable anatomic challenges to the insertion of the delivery catheter and graft deployment. The authors sought to evaluate whether large-diameter aneurysms and those with short proximal aortic necks might be associated with a higher frequency of insertion-related and short-term complications.

MATERIALS AND METHODS

From October 1999 to August 2000, 144 patients underwent elective endovascular graft placement for infrarenal AAA disease at the authors' institution. These patients were treated with use of the AneuRx bifurcated endoprosthesis. AAA size (maximum aneurysm diameter) and proximal aortic neck length were compared to estimated blood loss, operative time, accuracy of graft placement, presence of endoleak, intraoperative and postoperative complications (such as limb occlusion or vascular injury), length of hospital stay, and mortality. Statistical methods included correlation analysis and logistic regression.

RESULTS

There were 121 men and 23 women whose aneurysms ranged in size from 3 cm to 9.8 cm (mean, 5.6 cm; 95% CI, 5.4-5.8 cm). Endograft insertion was successful in all cases. There were three deaths within 30 days (2.1%) and seven deaths overall (4.9%). There were 43 intraoperative complications (29.9%) in 31 patients (21.5%), most of them minor. Patients with major intraoperative complications had significantly longer procedure times than those without complications (337 vs. 149 min; P <.0001). In the postoperative period (within 30 days), 31 complications (21.5%) occurred in 28 patients (19.4%), again most of them minor. AAA size was unrelated in any way to the rate of complications, but short proximal aortic neck length was associated with more serious intraoperative and postoperative complications (P =.0404 and P =.0230, respectively), and decreased 30-day and overall survival (P =.0240 and P =.0152, respectively).

CONCLUSIONS

Endovascular repair of large AAAs can be challenging; however, the size of the AAA does not influence the rate of complications. A short proximal aortic neck is the only significant risk factor for more serious complications.

Elevated plasma levels of matrix metalloproteinase-9 in patients with abdominal aortic aneurysms: a circulating marker of degenerative aneurysm disease

PURPOSE

Matrix metalloproteinase-9 (MMP-9) is abundantly expressed in abdominal aortic aneurysms (AAAs), where it plays a pivotal role in connective tissue destruction. Elevated plasma concentrations of MMP-9 (MMP-9PL) also have been reported in patients with AAAs, but it is unclear if this can distinguish patients with AAAs from those with atherosclerotic occlusive disease (AOD). The purpose of this study was to further define the utility of elevated MMP-9PL levels in the diagnosis and evaluation of AAAs, and to examine if changes in MMP-9PL can be used as a functional biomarker of degenerative aneurysm disease.

MATERIALS AND METHODS

Peripheral venous blood was obtained from 25 patients with AAAs, 15 patients with AOD, and five normal control subjects. MMP-9PL levels were determined by an enzyme-linked immunosorbent assay. In four patients undergoing open AAA repair, MMP-9PL levels were directly compared with the amount of MMP-9 produced in aortic tissue. Six additional patients undergoing operative AAA repair were followed for 3-10 months to determine how treatment affected elevated MMP-9PL concentrations.

RESULTS

Mean (+/- SE) MMP-9PL was 36.1 +/- 7.7 ng/mL in normal control subjects, 54.7 +/- 10.5 ng/mL in patients with AOD, and 99.4 +/- 17.4 ng/mL in patients with AAAs (P < .05 versus normal control subjects and patients with AOD). Elevated MMP-9PL levels (> 87.8 ng/mL) were found in 12 of 25 (48%) patients with AAA but in only one of 15 (7%) patients with AOD (P < .05). MMP-9PL levels did not correlate significantly with either age, gender, or aneurysm diameter, although there was a trend toward the highest values in male patients with large AAAs. Production of MMP-9 in aneurysm tissues paralleled MMP-9PL levels, and elevated MMP-9PL levels decreased by 92.7% +/- 3.2% after surgical AAA repair.

CONCLUSIONS

Elevated MMP-9PL levels were observed in approximately one half of patients with AAAs and less than 10% of those with AOD (positive predictive value of 92.3%), but normal MMP-9PL levels had limited utility in excluding the presence of an aortic aneurysm (negative predictive value, 52%). MMP-9PL levels in patients with AAAs appeared to directly reflect the amount of MMP-9 produced within aneurysm tissue, and MMP-9PL levels decreased substantially after aneurysm repair. Measures of circulating MMP-9 may provide a biologically relevant marker of connective tissue metabolism in patients with AAAs.

A review of selective salpingography and fallopian tube catheterization

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

Angioscopic observations after percutaneous thrombectomy of thrombosed hemodialysis grafts

PURPOSE

To use angioscopy to evaluate and compare the amount of residual thrombus and endoluminal wall damage in hemodialysis grafts after percutaneous thrombectomy procedures.

MATERIALS AND METHODS

Thirty-nine thrombectomy and angioscopy procedures were performed in 35 patients. Percutaneous thrombectomy methods included eight different mechanical thrombectomy devices and the "lyse and wait" technique. Videotaped images of 33 angioscopic examinations were independently reviewed by three radiologists. Two parameters-the amount of residual thrombus and degree of endoluminal wall damage-were scored on a scale of 1 to 5. Data were initially analyzed to validate the grading system and then further studied to compare the different thrombectomy techniques.

RESULTS

The Spearman rank order analysis validated the data pertaining to the amount of residual thrombus (r = 0.71, P < .0001), but there was poor correlation between reviewers regarding the degree of endoluminal wall damage. Combined scores from three reviewers revealed that the Cragg brush and Percutaneous Thrombectomy Device (PTD) left the smallest amounts of residual thrombus. The other methods tested, listed by increasing amount of residual thrombus, were the Endovac, Hydrolyser, Amplatz Thrombectomy Device, AngioJet, Oasis, and the lyse and wait technique. There were two complications related to angioscopy procedures.

CONCLUSION

Subjective observations reveal that wall-contact thrombectomy devices leave less residual thrombus than hydrodynamic devices, aspiration devices, or the lyse and wait technique.