Interventional Radiology in Canada: Current Challenges and Future Directions.

OBJECTIVE: We aim to define the practice of interventional radiology (IR) in Canada, barriers that have been faced by interventional radiologists, and ways in which the Canadian Interventional Radiology Association (CIRA) have attempted to address these issues. CONCLUSION: IR has faced significant challenges in the Canadian setting. Recognizing the need to address these challenges, leaders in the field of IR in Canada founded the CIRA to serve as our national voice and lobby group.

Portal Vein Embolization in the Setting of Staged Hepatectomy with Preservation of Segment IV ± I Only for Bilobar Colorectal Liver Metastases: Safety, Efficacy, and Clinical Outcomes.

PURPOSE: To assess frequency of adverse events, efficacy, and clinical outcomes of percutaneous portal vein embolization (PVE) in patients with bilobar colorectal liver metastases undergoing staged hepatectomy with preservation of segment IV ± I only. MATERIALS AND METHODS: Retrospective analysis was performed of 40 consecutive patients who underwent right PVE after successful left lobectomy between 2005 and 2013. Rates of adverse events, future liver remnant (FLR) > 30% compared with baseline liver volume, clinical success (completion of staged hepatectomy with clearance of liver metastases), and overall survival were analyzed. RESULTS: PVE was performed using polyvinyl alcohol particles (n = 7; 17.5%), particles plus coils (n = 23; 57.5%), and N-butyl cyanoacrylate glue plus ethiodized oil (n = 10; 25%). Technical success was 100%. After PVE, 20% (n = 8) of patients exhibited portal venous thrombosis, ranging from isolated intrahepatic portal branch thrombosis to massive thrombosis of the main portal vein (n = 3) and responsible for periportal cavernoma and portal hypertension in 5 patients. Of patients, 23 (57.5%) had FLR ≥ 30%, and 21 (52.5%) had clinical success. Six patients had significant stenosis or occlusion of the left portal vein or biliary system after original left lobectomy, which was independently associated with FLR < 30% (R2 = 0.24). Clinical success was the only independent variable associated with survival (R2 = 0.25). CONCLUSIONS: PVE for staged hepatectomy with preservation of segment IV ± I only is technically feasible, leading to adequate hypertrophy and clinical success rates in these patients with poor oncologic prognosis. Portal venous thrombosis is greater after the procedure than in the setting of standard PVE.

Analysis of arterial blood vessels surrounding the myoma: relevance to myomectomy.

OBJECTIVE: The optimal direction of myomectomy incision in relation to the blood vessels is unclear. Accordingly, we evaluated the location and course of arterial blood vessels surrounding the myoma. METHODS: This study is a retrospective analysis of 592 arterial blood vessels in 60 patients with symptomatic uterine leiomyomata undergoing uterine artery embolization. RESULTS: We encountered 592 arterial blood vessels surrounding the myoma. The vessels could be seen encircling the surface of the myoma. The dominant myoma was located on anterior (n=30), posterior (n=17), and fundal part of the uterus (n=13). There was no difference in the diameter (6.9+/-2.7 cm, 5.8+/-0.7 cm, and 6.7+/-0.5 cm) and volume of the myoma (268.6+/-52.7 cm(3), 197.0+/-64.5 cm(3), and 199.3+/-40.5 cm(3)) among anterior, posterior, and fundal, respectively. The vessels were graded as coursing with angles of 0-30 degrees, 30-60 degrees, and 60-90 degrees. There were significantly more blood vessels in the 30-60 degree group among anterior myoma (n=88, 42.5%) than in 0-30 degree (n=59, 28.5%, P=.004, 95% confidence interval [CI] 0.36-0.81) and 60-90 degree groups (n=60, 29.0%, 95% CI 1.2-2.7). Similar findings were found among posterior myoma (0-30 degrees n=26, 21.7%; 30-60 degrees n=59, 49.2%; P<.001, 95% CI 0.16-0.50; 60-90 degrees 35 (29.2%), P<.002, 95% CI 1.37-3.9). Among fundal myomas, there was no difference in the number of vessels in the 0-30 degree (n=28, 28.6%), 60-90 degree (n=40, 40.8%), and in 60-90 degree groups (n=30, 30.6%). CONCLUSION: Arterial blood vessels travel mostly diagonally on the surface of anterior and posterior myomas. There was no predominant pattern in the course of the arteries on fundal myomas. These findings suggest that regardless of the direction of the myomectomy incision, arterial blood vessels on myoma surface could be injured. LEVEL OF EVIDENCE: II.

Serial repositioning of a Günther tulip retrievable inferior vena cava filter in a pediatric patient.

We report an 11-year-old boy who required inferior vena cava (IVC) filtration for a prolonged period of time. A retrievable IVC filter was placed and repositioned three times, providing a total of 60 days of IVC filtration. The filter was removed when his risk of pulmonary embolus had decreased substantially. This is a relatively uncommon practice in the pediatric population. The technique is presented, and the available literature is reviewed.

Effect of transvaginal sonography on the use of invasive procedures for evaluating patients with a clinical diagnosis of ectopic pregnancy.

PURPOSE: Our purpose was to determine the effect of transvaginal sonography (TVS) on the diagnostic evaluation of patients with suspected ectopic pregnancy (EP). Specifically, we wished to determine what effect TVS had on the use of invasive procedures. METHODS: This was a retrospective review of the medical records of 290 patients with a surgically documented diagnosis of EP. It included 147 consecutive patients from the era of use of suprapubic sonography (SPS) (1982-1987) and 143 consecutive patients from the era of use of TVS (1987-1995). We compared the percentages of patients who had undergone sonographic examinations, the rates of use of the invasive procedures dilatation and curettage (D&C) and diagnostic laparoscopy (DL), time from presentation to diagnosis, necessity for transfusion, status of EP at surgery, and various other characteristics of the patients (eg, demographics, serum level of beta human chorionic gonadotropin, and presenting symptoms). RESULTS: In the SPS era, 46.9% of the patients had undergone sonography, compared with 78.3% in the TVS era (p = 0.001). Sonographic sensitivity was 60.9% in the SPS era and 93.8% in the TVS era (p = 0.001). D&C was performed in 53.1% and DL in 76.2% of patients in the SPS era, compared with 14.0% and 30.8%, respectively, in the TVS era (p = 0.001). In the last full year of the study, only 9% of the patients had undergone D&C and 9%, DL. The overall time from presentation to diagnosis significantly decreased from 45.6 hours in the SPS era to 16.8 hours in the TVS era (p = 0.002). We found no significant difference between the 2 eras in the need for transfusion and the percentage of ruptured EPs at surgery (p > 0.05). CONCLUSIONS: The introduction of TVS has had an important effect on the evaluation of patients with EP by nearly eliminating the need for D&C and DL and permitting clinicians to take a more conservative approach to managing EP.

Branched endovascular stent-graft for suprarenal aortic aneurysm: the future of aortic stent-grafting?

The use of a branched endovascular stent-graft to repair an aneurysm of the visceral aorta is described. The evolving role of branched endovascular stent-grafts in the management of aortic aneurysms is discussed, and the literature reviewed.