Splenic Artery Embolization in Blunt Trauma: A Single-Center Retrospective Comparison of the Use of Gelatin Sponge Versus Coils.

OBJECTIVE: The purpose of this study was to compare the efficacy of gelatin sponge with that of coils for splenic artery embolization in the treatment of blunt splenic injury. MATERIALS AND METHODS: A single-center retrospective review was performed with the records of 63 patients (45 men, 18 women; mean age, 45.5 years; range, 16-84 years) with blunt splenic injury treated at a tertiary care trauma center by splenic artery embolization with gelatin sponge (n = 30 patients) or metallic coils (n = 33 patients) between 2005 and 2014. The two groups had comparable median American Association for the Surgery of Trauma grades of IV and comparable angiographic appearances regarding active extravasation and pseudoaneurysm formation at preembolization splenic arteriography (p = 0.32). Clinical outcomes and procedure-related outcomes were evaluated. RESULTS: The success rates were similar in the two groups: splenic artery embolization failed in 6.6% (2/30) of patients in the gelatin sponge group and 12.1% (4/33) in the coil embolization group (p = 0.45; 95% CI, -30.1% to 19.2%). Major complications occurred in six patients (20.0%) in the gelatin sponge group and in six patients (18.1%) in the coil group (p = 0.85; 95% CI, -23.0% to 26.6%). Minor complications occurred in three patients (10.0%) in the gelatin sponge group and seven patients (21.2%) in the coil group (p = 0.21; 95% CI, -35.4% to 14.0%). Procedure time was significantly shorter in the gelatin sponge group (median, 32 minutes; interquartile range, 18-48 minutes) than in the coil group (median, 53 minutes; interquartile range, 30-76 minutes) (p = 0.01). CONCLUSION: Splenic artery embolization with gelatin sponge appears to be as effective and as safe as coil embolization and can be completed in a shorter time.

Randomized Trial Comparing the Primary Patency following Cutting Versus High-Pressure Balloon Angioplasty for Treatment of de Novo Venous Stenoses in Hemodialysis Arteriovenous Fistulae.

PURPOSE: A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arteriovenous (AV) fistulae for hemodialysis. MATERIALS AND METHODS: Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty with a cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 mm are not available. Nine patients were excluded after angiography, with seven requiring balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference, 9 y; P = .04), but other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo). Kaplan-Meier analysis was used to compare duration of patency. Mann-Whitney rank-sum t test and χ2/Fisher exact tests were used to compare continuous and categoric variables, respectively. RESULTS: Technical success was achieved in all 39 patients. At 3, 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI], 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%), 42.1% (95% CI, 20.25%-66.50%), and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval). CONCLUSIONS: Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

Outpatient uterine artery embolization for symptomatic fibroids: short- and long-term single institution-based outcomes.

OBJECTIVE: To assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis. METHODS: One hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded. RESULTS: UAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory. CONCLUSION: UAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.

Endoluminal dilation technique to remove "stuck" tunneled hemodialysis catheters.

Most tunneled catheters can be easily removed after the retention cuff is dissected. Occasionally, these catheters can become resistant to removal even after application of potentially hazardous forceful traction. In addition, an infected catheter may cause life-threatening septicemia. Several methods have been described for their extraction, some of which may be available only in tertiary-care facilities. The present report describes the successful extraction of five such "stuck" catheters by using a recently described technique of endoluminal dilation. The technique appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.

Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this meta-analysis was to determine the rates of major complications, other associated adverse events, reintervention, and clinical improvement from studies reporting complications of uterine artery embolization (UAE) for the treatment of symptomatic leiomyomas. MATERIALS AND METHODS: PubMed, Medline, Embase, and Cochrane databases were searched for publications on the treatment of leiomyomas by UAE. Data pertaining to study characteristics, numbers of complications, symptomatic improvement, and reinterventions were collected by two readers. Pooled event rates were calculated using a random effects method. RESULTS: Fifty-four study populations met the inclusion criteria, yielding a total of 8159 patients. There were no reported deaths. Major complications occurred at a rate of 2.9% (95% CI, 2.2-3.8%). The rate of hysterectomy for resolution of a complication from UAE was 0.7% (0.5-0.9%), and the rate of readmission was 2.7% (1.9-3.7%). Multiple other specific complications were recorded including leiomyoma tissue passage (4.7% [3.9-5.7%]), deep venous thrombosis or pulmonary embolism (0.2% [0.2-0.4%]), and permanent amenorrhea (3.9% [2.7-5.3%]). Reintervention rates including repeat UAE, myomectomy, or hysterectomy calculated per patient-year occurred at 5.3% (4.2-6.4%) with follow-up ranging from 0.25 to 5 years. Clinical symptomatic improvement ranged from 78% to 90%, with follow-up ranging from 0.25 to 2 years. CONCLUSION: Symptomatic uterine leiomyoma treatment by UAE is an effective procedure with a low rate of major complications supporting its use as an alternative to hysterectomy.

Case Report: Segmental Arterial Mediolysis, a Rare Cause of Hypertension.

RATIONALE: The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension. PRESENTING CONCERNS OF THE PATIENT: A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts. DIAGNOSES: After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made. INTERVENTIONS: Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation. OUTCOMES: The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events. TEACHING POINTS: Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.

JUSTIFICATION: Le diagnostic différentiel de l'hypertension avec élévation des concentrations plasmatiques de rénine est vaste. Le cas présenté illustre une des causes les plus rares et les moins connues de cette forme d'hypertension. PRÉSENTATION DU CAS: Un patient de 41 ans dont les antécédents médicaux montraient des dyslipidémies et des accidents ischémiques cérébraux multiples s'est présenté pour une réduction de la fonction rénale et une hypertension résistante. Le premier bilan des causes secondaires de l'hypertension se distinguait par une concentration plasmatique élevée de rénine et une aldostérone normale. L'angiographie par tomodensitométrie a révélé de multiples anévrismes et infarctus rénaux bilatéraux. DIAGNOSTIC: Après avoir écarté les autres causes potentielles d'anévrismes et d'infarctus rénaux bilatéraux, un diagnostic de médiolyse artérielle segmentaire a été posé. INTERVENTIONS: Optimisation du traitement antihypertenseur, encadrement quant à la surveillance régulière de la pression artérielle à domicile et abandon du tabac. RÉSULTATS: Le patient a réussi à contrôler sa pression artérielle, sa fonction rénale s'est stabilisée et aucun autre événement vasculaire n'est survenu. LEÇONS TIRÉES: Ce cas souligne l'importance d'envisager la médiolyse artérielle segmentaire comme affection analogue de la vascularite, et d'en tenir compte dans le diagnostic de l'hypertension avec élévation de la concentration plasmatique de rénine. Ce cas insiste également sur l'importance de considérer l'imagerie vasculaire rénale dans l'étude de l'hypertension résistante.

Vertebral pseudolesion on lateral chest radiograph.

OBJECTIVE: The purpose of this study was to describe and explain the basis for the lateral chest radiographic finding of a pseudolesion simulating a sclerotic vertebral lesion. CONCLUSION: Superimposition of the scapula on the upper thoracic spine causes a vertebral pseudolesion that simulates a sclerotic lesion.

Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.

An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula. An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.

The bedside investigation of pulmonary embolism diagnosis study: a double-blind randomized controlled trial comparing combinations of 3 bedside tests vs ventilation-perfusion scan for the initial investigation of suspected pulmonary embolism.

BACKGROUND: We sought to determine whether using combinations of 3 bedside tests (7-variable clinical model, non-enzyme-linked immunosorbent assay D-dimer test, and alveolar dead-space fraction) to exclude pulmonary embolism (PE) before diagnostic imaging was as safe as a standard strategy of starting with ventilation-perfusion (V/Q) scan. METHODS: In this double-blind, randomized, controlled equivalency trial, patients were randomized to initial bedside tests or to initial V/Q scan without bedside tests. Patients assigned to the bedside test group had a sham V/Q scan performed if at least 2 of 3 bedside test results were negative; otherwise, they underwent an actual V/Q scan. Further diagnostic management was determined by a blinded physician after V/Q scan. The primary outcome measure was recurrent venous thromboembolic events during 3 months among patients who were not taking anticoagulant agents after the initial investigations were completed. RESULTS: Four hundred fifty-eight consecutive adults with suspected PE were eligible for the study; 398 of 399 consenting and randomized patients completed the study. The follow-up venous thromboembolic event rate was 2.4% in the bedside test group vs 3.0% in the V/Q scan group (P = .76). Pulmonary embolism was excluded in 34% (67/199) of the bedside test group patients with at least 2 negative results on 3 bedside tests vs 18% (35/199) excluded using only the 7-variable clinical model and the D-dimer test. CONCLUSION: Excluding PE with at least 2 negative results on 3 bedside tests safely eliminates the need for diagnostic imaging in 34% of patients with suspected PE.

Factors influencing the yield of mesenteric angiography in lower gastrointestinal bleed.

AIM: To assess if certain triaging rules could be established to optimize the yield of mesenteric angiography. METHODS: Medical records of 101 patients were retrospectively reviewed and parameters relating to age, gender, pulse rate, blood pressure, serum hemoglobin, intensive care unit (ICU) admission, and the number of packed red blood cells (PRBC) transfused in the 12 and 24 h prior to the angiography were tabulated in two groups with positive and negative angiography results. RESULTS: We found no correlation between gender, pulse rate, blood pressure or serum hemoglobin and positivity of the mesenteric angiogram. But patients with positive angiogram were found to be on average 7 years older (73.2 years vs 65.9 years old) (P = 0.02). Angiogram was positive in 39.3 % (11/28) of patients admitted in ICU vs 23.2% (17/73) who were admitted elsewhere in the hospital (P = 0.03). In the 12 and 24 h prior to angiography, patients with a positive angiogram received a mean of 2.7 ± 2.3 and 3.3 ± 2.6 units of PRBC s respectively, while patients with a negative angiogram had a mean of 1.6 ± 1.9 (P = 0.02) and 2.1 ± 2.6 units (P = 0.04) received respectively in the same period. CONCLUSION: Older age, ICU admission, having received at least 4 units PRBC over 12 h or 5 units over 24 h prior to angiogram are leading indicators for a positive study.

Spherical versus conventional polyvinyl alcohol particles for uterine artery embolization.

PURPOSE: To compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE). MATERIALS AND METHODS: Of 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure. RESULTS: On 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations. CONCLUSIONS: In comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

Significant caval penetration by the celect inferior vena cava filter: attributable to filter design?

This report describes transmural penetration of the inferior vena cava (IVC) by a newly introduced IVC filter within 9 days of its placement. A computed tomographic study demonstrated filter penetration with one of the primary struts lodging in the uncinate process of the pancreas. Because of the close resemblance of this new filter to another filter that has not been associated with penetration injuries, the key differences between the two designs were examined and the determination was made that the new filter, unlike the older one, has unprotected primary struts. Only filters with an unprotected primary strut design have been associated with penetration injuries such as the one described in this case.

Superior hypogastric nerve block for pain control in outpatient uterine artery embolization.

PURPOSE: To assess the efficacy of the superior hypogastric nerve block (SHNB) in permitting uterine artery embolization (UAE) to be performed as a routine outpatient procedure. MATERIALS AND METHODS: One hundred thirty-nine patients who underwent UAE in a prospective single-arm clinical trial in an academic institution underwent SHNB from an anterior abdominal approach to control acute postprocedural pain, in addition to conventional conscious sedation. They were discharged and prescribed one of two drug combinations started during the in-hospital recovery period. Regimen A included short-acting morphine tablets and indomethacin rectal suppositories and regimen B included long-acting morphine tablets for baseline pain supplemented with short-acting morphine tablets for breakthrough pain, and naproxen rectal suppositories. All patients were contacted by phone on the third and fifth postprocedural days and their peak pain experience was recorded on a scale of 0 to 10. RESULTS: All patients were able to be discharged the day of the procedure. Seven patients (5%) returned to the hospital because of pain. One was discharged after undergoing a second SHNB and four were discharged after receiving intravenous analgesics; two required longer admission for intravenous analgesia. The mean (+/-SD) peak pain score in the first 5 days after the procedure for all patients was 4.8 +/- 2.6. There was a significant difference between regimens A (mean pain score, 5.7 +/- 2.2) and B (mean pain score, 2.7 +/- 2.5; Mann-Whitney, 5.94; P < .01). CONCLUSION: The addition of SHNB to the more conventional post-UAE pain management methodology enhances pain control, enabling the procedure to be offered with minimum pain on a routine outpatient basis.