Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial.

OBJECTIVES: To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. DESIGN: Economic evaluation alongside the FEMME randomised controlled trial. SETTING: 29 UK hospitals. POPULATION: Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). METHODS: A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. MAIN OUTCOME MEASURES: Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. RESULTS: Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). CONCLUSIONS: Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures. TWEETABLE ABSTRACT: Fully informed women with uterine fibroids should have a choice between uterine artery embolisation or myomectomy.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure.

OBJECTIVES: To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall. METHODS: Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups. RESULTS: Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044). CONCLUSION: Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta.

AIM: To report experience of prophylactic occlusion balloon catheters (POBCs) in both internal iliac arteries before caesarean section, with or without embolization, to preserve the uterus and reduce haemorrhage. METHODS AND MATERIALS: Twenty-seven women diagnosed with morbidly adherent placenta (MAP) and with suspected placenta percreta underwent POBC placement before caesarean section. The balloons were inflated immediately after delivery of the baby. The patients' case notes were reviewed retrospectively for histological grading of MAP, blood loss, transfusion, requirement of uterine artery embolization (UAE), or hysterectomy, radiation dose, and infant or maternal morbidity and mortality. RESULTS: MAP was confirmed histologically as percreta in 17, accreta in eight, and increta in two women. Mean blood loss was 1.92 l (range 0.5-12 l). Postpartum haemorrhage (PPH) occurred in nine patients. Eight were referred for UAE, which was successful in six. Immediate peri-partum hysterectomy was performed in one patient. Three women in total required hysterectomy, two after recurrent haemorrhage after UAE. No foetal morbidity or mortality occurred. No maternal mortality occurred. There was one case of iliac artery thrombosis, which resolved with conservative therapy. CONCLUSION: POBC, with or without UAE, contributes to reduction of blood loss and preservation of the uterus in women with MAP.

Outcome of aortoiliac, femoropopliteal and infrapopliteal endovascular interventions in lesions categorised by TASC classification.

AIM: To analyse lower limb angioplasty results using the defined anatomical classification of the Trans-Atlantic Inter-Society Consensus (TASC) in a training environment and to compare the results with published data. MATERIALS AND METHODS: Retrospective, consecutive data were collected for a period of 1 year for all patients undergoing lower limb endovascular interventions. The radiology information system and notes were used to obtain clinical data, and angiograms were reviewed in all cases. All cases were performed or supervised by five vascular interventional consultants assisted by fellows or registrars. Patient demographics, the indication for treatment, the TASC classification of the treated lesion, calcification, use of stent, technical success (residual stenosis <20% on completion angiography), and complications were assessed. RESULTS: Two hundred and sixty-two lesions were treated. Of the aortoiliac lesions (83), the overall primary technical success rate was 91.6% (TASC A and B: 96.7%, TASC C and D: 77.3%). Sixty-one lesions were stented and no complications recorded. Of the femoropopliteal lesions (n = 123), the overall primary technical success rate was 91.9% (TASC A and B: 98.7%, TASC C and D: 80.9%). There were four major and five minor complications in this group (five groin haematomas, two vessel ruptures, one retroperitoneal haematoma, and one distal embolization). Five patients were stented. In the infrapopliteal group (n = 56), the overall primary technical success rate was 91.1% (TASC A and B: 96.3%, TASC C and D: 86.2%). There was one complication (small retroperitoneal hematoma) and two stents were used. CONCLUSION: The results of the present study showed good technical success and low complication rates in lower limb endovascular interventions with variable operator expertise. The results are comparable to published data. Use of the TASC classification system is encouraged as it allows an objective assessment of severity and enables standardized comparison.

Technique and outcomes of isolated limb infusion for locally advanced malignant melanoma--a radiological perspective.

AIM: Isolated limb infusion (ILI) is a novel, minimally invasive technique for delivering high-dose regional chemotherapy in patients with recurrent and in-transit melanoma. The aim of this study was to review our single-centre experience in treating eleven patients. We emphasize the role of radiologists in setting up this service, including pre-treatment workup and placement of vascular catheters. MATERIALS AND METHODS: A retrospective analysis of 11 patients who underwent 12 procedures between 2005 and 2009 was performed. Pre-procedural staging computed tomography (CT), CT angiography, and duplex studies were performed. All patients received a cytotoxic combination of melphalan and actinomycin-D via radiologically placed arterial and venous catheters in the affected limb under mild hyperthermic conditions. The outcome measures include response rates, limb toxicity, complications, and survival. RESULTS: All patients were female with a mean age of 72 years. Three patients had American Joint Committee on Cancer (AJCC) stage IIIB melanoma, seven had stage IIIC melanoma, and one had a stage IIIB Merkel cell tumour. Complete response was seen in five patients (46%), partial response in four (36%), and progressive disease in two (18%). One patient developed grade 4 toxicity requiring a fasciotomy and another experienced systemic toxicity. CONCLUSION: These outcomes are comparable to previous studies and shows that ILI is effective in locoregional control of unresectable melanoma. It is a relatively safe procedure but not without risk. Our experience shows the importance of radiological input to ensure safe and effective delivery of services.

Post-traumatic pelvic pseudoaneurysm and arterio-venous fistula: combined endovascular and surgical approach.

Post-traumatic pelvic pseudoaneurysms are rare and challenging to manage. We describe the combined endovascular and surgical strategy used, to successfully treat a large internal iliac pelvic pseudoaneurysm combined with arterio-venous fistula, in a patient presenting 20 years following an elective caesarean section.

Radiological treatment of symptomatic uterine fibroids.

Uterine artery embolization (UAE) is a relatively new alternative treatment for symptomatic fibroids. Recent Level 1 evidence from two major randomized controlled trials has established UAE as a safe and effective alternative to hysterectomy. Technical aspects, choice of embolic agent, safety, contra-indications and complications of the procedure will be reviewed. The available data on the effects on ovarian function, fertility and pregnancy outcomes following UAE will be presented.

Endovascular repair of iliac artery injury complicating lumbar disc surgery.

Vascular injury as a complication of disc surgery was first reported in 1945 by Linton and White. It is a rare but potentially fatal complication. The high mortality rate (40-100%) is attributed to a combination of rapid blood loss and the failure to recognise the cause of the deteriorating patient. Early diagnosis and treatment is essential. Treatment has traditionally been by open vascular surgical repair, however with modern imaging and endovascular techniques, minimally invasive treatment should be considered first line in patients who are stable. We present the case of a 51-year-old woman who sustained common iliac artery injury during lumbar spinal surgery that was treated successfully using a covered stent.

Transcatheter pelvic arterial embolisation for control of obstetric and gynaecological haemorrhage.

We present a 5-year experience of pelvic arterial embolisation at two centres in the UK, and emphasise the role of interventional radiology in the treatment of obstetric and gynaecological haemorrhage. A total of 31 women underwent pelvic embolization:19 patients had complete medical records, and of these, two women had antepartum haemorrhage, 12 women had primary postpartum haemorrhage (PPH), four women had secondary PPH and one woman had a haemorrhage following termination of pregnancy (TOP). The source of the haemorrhage was only identified in four women (21.1%). All patients underwent selective embolisation of the uterine artery or anterior divisional branch of the internal iliac artery with successful haemorrhage control in 17 patients (89.4%) and no immediate complications. Haemorrhage continued despite embolisation in two patients; both proceeded to surgery. Selective pelvic embolisation is a safe and effective treatment for acute obstetric or gynaecological haemorrhage and should be part of the management algorithm for PPH.

Arterial closure devices. A review.

The use of arterial closure devices in achieving haemostasis following arterial puncture has become increasingly popular. This review aims to provide an overview of the currently available closure devices, with an up-to-date summary of the supporting literature. The various devices have their advantages and disadvantages as well as differing mechanisms of actions. Technical aspects of deployment affect the learning curve and ease of use of individual devices. Some complications that arise are device specific where others are related to arterial punctures in general. When choosing a device, all these factors should be taken into account as well as differing clinical requirements and priorities. Most studies of arterial closure devices that are currently in use conclude that the safety profile of closure devices is comparable to manual compression. The literature does not show superiority of any particular device. Caution is advised in extrapolating evidence based on differing patient groups, as many of the study populations are heterogeneous. As physicians become more familiar with the use of closure devices, off-label applications of some devices have emerged, some of which need further evaluation. The ideal closure device should reduce complication rates compared to manual compression, be easy to use with a short learning curve, and have a high rate of deployment success. It should also be usable across a wide range of sheath sizes, not leave any permanent foreign body behind, reduce time to haemostasis and ambulation, allow immediate repuncture, improve patient comfort and be cost effective. In spite of the wide range of devices currently available there remains room for improvement.

"Apparent" heart failure: a syndrome caused by renal artery stenoses.

OBJECTIVE: To report on renal artery stenosis presenting as congestive heart failure. DESIGN: Case series. SETTING: Tertiary referral centre. PATIENTS: Nine hypertensive subjects (five male, four female) seen in the blood pressure unit, St George's Hospital, between 1991 and 1997 with clinical signs and symptoms of congestive cardiac failure but without overt coronary or valvar heart disease. Mean (SEM) age was 67 (3) years. Eight patients had renal artery revascularisation with percutaneous angioplasty and one had surgery. RESULTS: Renal revascularisation was followed by a large fall in blood pressure from 191/94 (7/3) to 150/75 (8/5) mm Hg two days after intervention (p < 0.01). There was also a large natriuresis and weight reduction. One week after revascularisation there was a mean loss in weight of 3.8 (0.6) kg. The largest fall in weight was seen in those patients with stenosis in a single functioning kidney. Furthermore, plasma atrial natriuretic factor fell from 120 (28) to 48 (9) pg/ml (p < 0.05; n = 6; normal value = 8.6 (0.8) pg/ml), and serum creatinine fell from 200 (37) to 140 (11) micromol/l (p < 0. 025). The clinical signs and symptoms of heart failure resolved and the diuretics were then withdrawn in all patients. On long term follow up, patients remained free from symptoms and signs of heart failure and the blood pressure was better controlled. CONCLUSIONS: In hypertensive patients with symptoms and signs of congestive heart failure who do not have obvious ischaemic or valvar heart disease, renal artery stenosis should be considered as a possible underlying cause. Relief of the stenosis can result in resolution of the apparent heart failure.

The future of arteriography and vascular interventional radiology.

Non-invasive vascular imaging techniques threaten to diminish the catheter skills which radiology trainees currently acquire during diagnostic angiography. This, coupled with the desire of some vascular surgeons to perform minimally invasive "endovascular surgery", may threaten the future of this radiological subspecialty, or perhaps it will help to create a new discipline incorporating surgical, medical and radiological skills.

The role of infrapopliteal angioplasty.

Infrapopliteal percutaneous transluminal angioplasty (PTA) is currently indicated in patients with critical limb ischaemia (CLI). It may be performed after femoral angioplasty or bypass surgery, to improve outflow and hence patency of the proximally treated segment. Patients with CLI are typically elderly with multiple co-morbidities and limited life expectancy and therefore, a procedure, which is minimally invasive with reduced morbidity and mortality but lesser long-term patency, may be more appropriate than a more invasive procedure with better long-term patency. Clinical success is superior to angiographic patency, because once healing has occurred, should the artery restenose or occlude, collateral flow can be sufficient to preserve tissue integrity if there is no further injury. Although no prospective randomized trials have been performed, the reported limb-salvage rates of PTA are comparable with surgery. As PTA carries a lower morbidity and mortality, shorter hospital stay and does not preclude surgery, it is ideal for this group of patients who are high-risk surgical candidates. Improvements in guide-wire and catheter technology and recanalization techniques mean that very long stenoses or occlusions, and multiple lesions can be treated successfully. At the current time, PTA is the treatment of choice for infrapopliteal occlusive disease; experience with the use of stents in this territory is increasing but currently insufficient to justify their primary use.

The renal rind sign: a new ultrasound indication of inflammatory disease in the abdomen.

The width of the right anterior extrarenal tissue is increased on ultrasound examination in patients with abdominal inflammatory disease. Thickened perirenal fascia associated with acute pancreatitis has previously been reported on computed tomography. A case report has described increased echogenicity of the pararenal space on ultrasound in children with pancreatitis but increased width of the space between the liver and the renal capsule has not hitherto been described in association with inflammatory disease in the abdomen in adults. We have observed it in acute cholecystitis, acute pancreatitis, acute appendicitis, a perforated duodenal ulcer, a leaking anastomosis with a right subphrenic abscess following total gastrectomy and in a patient with septicaemia and liver abscesses. Normal values were obtained in 100 patients without detectable or known disease and were found to be between 1 and 6 mm (mean 2.5 mm) in men and 1 and 5 mm (mean 1.8 mm) in women. The patients with abdominal disease who demonstrated this sign had values ranging from 9-11 mm (mean 10 mm).

Superior mesenteric artery stenting for mesenteric ischaemia in Sneddon's syndrome.

Mesenteric ischaemia is a rare but serious cause of abdominal pain. We present the case of a man with Sneddon's syndrome, who had symptomatic mesenteric ischaemia secondary to a superior mesenteric artery stenosis in conjunction with a hepatic artery stenosis. As far as the authors are aware, this has not previously been described in Sneddon's syndrome, which is a vascular systemic disease characterized by an association between cerebrovascular accidents and a livedo reticularis skin rash. He was treated with balloon angioplasty and stent insertion, with good symptomatic improvement. This has implications for other stenoses in this condition should they become symptomatic.

Demonstration of renal arterial anatomy and tumour neovascularity for vascular mapping of renal cell carcinoma: the value of CO2 angiography.

The aim of this study was to compare the efficacy of CO(2) angiography with that of iodinated contrast angiography for vascular mapping prior to partial nephrectomy for presumed renal cell carcinoma. 13 consecutive patients were studied and all patients underwent selective renal angiography using both CO(2) and iodinated contrast medium. Digitally subtracted images were acquired and compared. Seven male and six female patients, with a median age of 58 years (range 46-74 years), were examined. On comparing images the main renal artery was visualized in all cases with both contrast agents. The segmental vessels were seen in 7 of 13 CO(2) studies and 12 of 13 iodinated contrast studies. CO(2) was also inferior in the depiction of tumour circulation, showing it in 4 of 13 cases compared with 9 of 13 cases using iodinated contrast. It therefore appears that CO(2) angiography offers no diagnostic advantage and is also inferior to iodinated contrast angiography in the pre-operative vascular mapping of renal tumours.

Radiographic appearance of frontal osteomyelitis in two patients with extradural abscess.

Extradural abscess can be a complication of frontal sinusitis. The chronicity of this condition can give rise to extreme frontal hyperostosis which can be an important radiological sign in a condition which may be clinically obscure.

Diagnostic angiography performed by nurses.

The aim of this study was to assess the feasibility of a nurse performing diagnostic angiography. After a theoretical and practical training course on the techniques of arterial catheterization, the nurse performed diagnostic angiography under supervision on 68 patients. Patients with impalpable femoral pulses or scarred groins as well as obese patients were excluded. Successful arterial catheterization was achieved in 58 (85%) patients. Complications were limited to a severe haematoma requiring surgery in one patient and seven minor self-limiting haematomas. On this evidence, it is feasible and safe for appropriately trained nurses to perform angiography in radiology departments that have limited radiology staffing levels and no non-invasive alternations to catheter-based angiography.

Renal angiography using carbon dioxide.

The many advantages of carbon dioxide (CO2) angiography in the investigation of renal arterial disease include an absence of both nephrotoxicity and allergic reactions. An automated delivery system facilitates injection of CO2 whilst ensuring that there is no contamination of the injection with air. We report our initial experience using a prospective study of this delivery system in 47 patients referred for renal angiography, and assess diagnostic image quality and adverse reactions to CO2 angiography using the automated delivery system. The majority (37/47; 79%) of angiograms were of diagnostic quality and there were no significant adverse reactions in response to the CO2 contrast agent.