RESUMO
OBJECTIVE: To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. DESIGN: A stepwise video demonstration with narration. SETTING: A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. INTERVENTIONS: A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.
Assuntos
Malformações Arteriovenosas , Laparoscopia , Gravidez , Feminino , Humanos , Adulto , Cesárea , Perda Sanguínea Cirúrgica , Cicatriz/cirurgia , Útero/cirurgia , Útero/patologia , Malformações Arteriovenosas/etiologia , Malformações Arteriovenosas/cirurgia , Laparoscopia/métodosRESUMO
BACKGROUND: To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. METHODS: Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. RESULTS: Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). CONCLUSIONS: Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.
Assuntos
Fístula Anastomótica/terapia , Doenças dos Ductos Biliares/terapia , Transplante de Fígado , Complicações Pós-Operatórias/terapia , Pré-Escolar , Colangiopancreatografia Retrógrada Endoscópica , Constrição Patológica/terapia , Dilatação , Feminino , Humanos , Masculino , Estudos Retrospectivos , StentsRESUMO
PURPOSE: The purpose of this study was to evaluate the effectiveness and adverse outcomes of percutaneous cryoablation (CA) for treatment of renal masses in a large cohort of patients. MATERIALS AND METHODS: This retrospective analysis included 299 CA procedures (297 masses in 277 patients) performed between July 2007 and May 2018 at a single institution. The mean patient age was 66.1 years (range, 30-93 years) with 65.8% being male. A total of 234 (78.8%) masses were biopsy-proven renal cell carcinoma (RCC). The mean maximal tumor diameter was 2.5 cm (range, 0.7-6.6 cm). Efficacy was assessed only for ablations of biopsy-proven RCC, whereas the evaluation of adverse events and renal function included all masses. Complications were graded according to the Society of International Radiology classification. RESULTS: Major complications occurred in 3.0% of procedures (n = 9), none of which resulted in death or permanent disability. The mean imaging follow-up period was 27.4 months (range, 1-115) for the 199 RCC patients (204 ablated tumors) with follow-up imaging available. Complete response on initial follow-up imaging at mean 4.2 months (range, 0.3-75.6) was achieved in 195 of 204 tumors (95.6%) after a single session and in 200 of 204 tumors (98.0%) after 1 or 2 sessions. Of the RCC patients achieving complete response initially, local recurrence during the follow-up period occurred in 3 of 200 tumors (1.5%). Metastatic progression occurred in 10 of 193 (5.2%) RCC patients without prior metastatic disease during follow-up. CONCLUSIONS: CA for renal masses is safe and remains efficacious through intermediate- and long-term follow-up.
Assuntos
Carcinoma de Células Renais/cirurgia , Criocirurgia , Neoplasias Renais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Carcinoma de Células Renais/secundário , Criocirurgia/efeitos adversos , Progressão da Doença , Feminino , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Carga TumoralRESUMO
PURPOSE: To evaluate the evolving representation of women in the Society of Interventional Radiology (SIR). MATERIALS AND METHODS: A retrospective review of the available gender demographic data of various SIR subgroups between 2008 and 2017 was performed. The gender makeup of the following groups was analyzed: SIR membership, SIR Executive Council members and officers, Annual Meeting invited speakers, committee chairs, Journal of Vascular and Interventional Radiology (JVIR) first and senior authors, JVIR editorial board, IR Quarterly (IRQ) authors, and active interventional radiology (IR) residents and fellows. RESULTS: From 2008 to 2017, the percentage of female representation in SIR members doubled (from 6% to 13.1%). In the same period, female representation also significantly increased in Executive Council members (0% to 20%) and officers (0% to 50%), SIR Annual Meeting presenters (5.1% to 15.4%), and JVIR first authors (10% to 14.5%) and senior authors (7.1% to 11.9%). From 2012 to 2017, there were increases in female representation among SIR committee chairs (21% to 28%) and IRQ authors (4.5% to 27%). However, the percentage of female IR residents and fellows did not significantly change between 2008 and 2017 (11% vs 16.2%; P = .51). CONCLUSIONS: Women interventional radiologists are underrepresented within SIR, representing only 9.2% of active IR physicians. There has been a steady increase in female representation within most areas of SIR evaluated in this study. Although these trends are reassuring, efforts toward increasing recruitment and retention of women in IR need to improve in light of the infancy of IR as a residency program.
Assuntos
Escolha da Profissão , Médicas/tendências , Radiologistas/tendências , Radiologia Intervencionista/tendências , Sexismo/tendências , Especialização/tendências , Mulheres Trabalhadoras , Congressos como Assunto/tendências , Educação de Pós-Graduação em Medicina/tendências , Feminino , Humanos , Masculino , Radiologistas/educação , Radiologia Intervencionista/educação , Estudos Retrospectivos , Sociedades Médicas/tendências , Mulheres Trabalhadoras/educaçãoRESUMO
PURPOSE: To determine the clinical outcomes of patients who underwent image-guided drainage of peripancreatic fluid collections after simultaneous pancreas-kidney (SPK) transplantation. MATERIALS AND METHODS: A retrospective review of all patients who underwent peripancreatic fluid collection drainage after SPK, from January 2000 to August 2017, at a single institution was performed. Patient characteristics, surgical technique, medication regimen, microbial analysis, and clinical outcomes were reviewed. Thirty-one patients requiring a total of 41 drainages were included in this study. The median age was 44 years (range 30-58 years), and median time between SPK and drainage was 28 days (range 8 to 3,401 days). Fisher's exact test, unpaired Student t-tests, and Pearson correlations were used for statistical analysis. RESULTS: Fever (51%) and abdominal pain (31%) were the most common presenting symptoms. The average amount of fluid drained at the time of drain placement was 97 mL (SD 240 mL). The average time spent with a drain in place was 33 days (SD 31 days). Microorganisms were isolated in the fluid of 22 of 41 drainages (54%), with mixed gastrointestinal flora being the most common. No further intervention was needed in 34 of 41 drainages (82%). However, drainage failed in 5 of 31 patients (16%), requiring surgical intervention with removal of the pancreas transplant. CONCLUSIONS: Percutaneous drainage of peripancreatic fluid collections after SPK transplantation is a safe and effective treatment option.
Assuntos
Drenagem/métodos , Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Complicações Pós-Operatórias/terapia , Adulto , Drenagem/efeitos adversos , Drenagem/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Opportunities for interventional radiology (IR) education and exposure remain limited at medical institutions without a local IR presence, thereby excluding a medical student population with potential to pursue careers in IR or become referring providers to IR. The purpose of this study was to evaluate the efficacy of a Webinar-based IR elective as an educational tool for outreach to US medical schools lacking local preclinical IR exposure. Our early results indicate that a Webinar-based IR lecture series can serve as an effective method for educating future physicians about the field of IR and when to consult IR for patient management.
Assuntos
Escolha da Profissão , Instrução por Computador/métodos , Educação de Graduação em Medicina/métodos , Internet , Radiologistas/educação , Radiologia Intervencionista/educação , Especialização , Estudantes de Medicina , Currículo , Feminino , Humanos , MasculinoRESUMO
PURPOSE: To evaluate efficacy and safety of transjugular liver biopsy (TJLB) via the left hepatic vein in patients with left lobe-only liver transplants (LLOTs). MATERIALS AND METHODS: Retrospective review revealed 43 TJLBs performed in 26 patients with LLOTs (mean age 51.3 y; range, 18-73 y) between January 2009 and June 2016 at a single institution. A comparison group of 44 randomly selected TJLBs performed in 37 orthotopic whole liver transplant (OWLT) recipients (mean age 57.6 y; range, 35-74 y) during the same time period was evaluated. Patient demographics, type and age of transplant, technical success, adequacy of samples, number of portal tracts obtained, pathologic diagnosis, and complication rate were reviewed. RESULTS: Technical success was achieved in 98% (42/43) of LLOT procedures. TJLB failed in 1 patient with LLOT, in whom no patent hepatic veins were identified. Technical success was achieved in 100% (44/44) in the OWLT group. Mean (SD) number of needle passes was 4.12 (1.25) in the LLOT group vs 3.95 (1.28) in the OWLT group (P = .54). Mean (SD) specimen length was 1.16 (0.75) cm in the LLOT group vs 1.19 (0.58) cm in the OWLT group (P = .78). Mean (SD) number of portal tracts obtained in the LLOT group was 10.7 (5.26) vs 12.3 (4.68) in the OWLT group (P = .17). No major complications were observed in either group. CONCLUSIONS: TJLB in adult patients with LLOTs appears safe and feasible, with favorable rates of technical success and adequacy of sampling.
Assuntos
Biópsia por Agulha/métodos , Cateterismo Venoso Central/métodos , Veias Hepáticas , Biópsia Guiada por Imagem/métodos , Veias Jugulares , Transplante de Fígado , Complicações Pós-Operatórias/patologia , Adolescente , Adulto , Idoso , Angiografia Digital , Biópsia por Agulha/efeitos adversos , Cateterismo Venoso Central/efeitos adversos , Feminino , Veias Hepáticas/diagnóstico por imagem , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Veias Jugulares/diagnóstico por imagem , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Flebografia , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Radiografia Intervencionista , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Adulto JovemRESUMO
PURPOSE: To assess the effectiveness of disposable radiation-absorbing surgical drapes on operator radiation dose during transjugular liver biopsy (TJLB). MATERIALS AND METHODS: This dual-arm prospective, randomized study was conducted between May 2017 and January 2018 at a single institution. TJLB procedures (N = 62; patient age range, 19-80 y) were assigned at a 1:1 ratio to the use of radiation-absorbing surgical drapes or standard surgical draping. The primary outcome was cumulative radiation equivalent dose incident on the operator, as determined by an electronic personal dosimeter worn at the chest during each procedure. Cumulative kerma-area product (KAP), total fluoroscopy time, and total number of exposures used during each liver biopsy procedure were also determined. RESULTS: Mean radiation dose incident on the operator decreased by 56% with the use of radiation-absorbing drapes (37 µSv ± 35; range, 4-183 µSv) compared with standard draping (84 µSv ± 58; range, 11-220 µSv). Radiation incident on the patient was similar between groups, with no significant differences in mean KAP, total fluoroscopy time, and number of exposures acquired during the procedures. CONCLUSIONS: Use of disposable radiation-absorbing drapes reduces scatter radiation to interventionalists performing TJLB.
Assuntos
Biópsia Guiada por Imagem/instrumentação , Hepatopatias/diagnóstico por imagem , Exposição Ocupacional/prevenção & controle , Saúde Ocupacional , Exposição à Radiação/prevenção & controle , Proteção Radiológica/instrumentação , Radiografia Intervencionista/instrumentação , Radiologistas , Campos Cirúrgicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Equipamentos Descartáveis , Feminino , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Hepatopatias/patologia , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Projetos Piloto , Estudos Prospectivos , Fatores de Proteção , Doses de Radiação , Dosímetros de Radiação , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Fatores de Risco , São Francisco , Espalhamento de Radiação , Adulto JovemRESUMO
PURPOSE: To assess radiation dose reduction during uterine fibroid embolization (UFE) using an optimized angiographic processing and acquisition platform. MATERIALS AND METHODS: Radiation dose data for 70 women (mean age, 46 y; range, 34-67 y) who underwent UFE were retrospectively analyzed. Twenty-one patients underwent UFE using the baseline fluoroscopic and angiographic image acquisition platform, and 49 underwent UFE after implementing an optimized imaging platform in otherwise identical angiography suites. Cumulative kerma-area product (CKAP), cumulative air kerma (CAK), total fluoroscopy time, and image exposure number were collected for each procedure. Image quality was assessed by 3 interventional radiologists blinded to the platform used for image acquisition and processing. RESULTS: Patients undergoing UFE using the new x-ray fluoroscopy platform had significantly lower CKAP and CAK indicators than patients for whom baseline settings were used. Mean CKAP decreased by 60% from 438.5 Gy · cm2 (range, 180.3-1,081.1 Gy · cm2) to 175.2 Gy · cm2 (range, 47.1-757.0 Gy · cm2; P < .0001). Mean CAK decreased by 45% from 2,034.2 mGy (range, 699.3-5,056.0 mGy) to 1,109.8 mGy (range, 256.6-4,513.6 mGy; P = .001). No degradation of image quality was identified through qualitative evaluation. CONCLUSIONS: Significant reduction in patient radiation dose indicators can be achieved with use of an optimized image acquisition and processing platform.
Assuntos
Embolização Terapêutica/métodos , Leiomioma/diagnóstico por imagem , Leiomioma/terapia , Proteção Radiológica/métodos , Radiografia Intervencionista , Neoplasias Uterinas/diagnóstico por imagem , Neoplasias Uterinas/terapia , Adulto , Idoso , Angiografia Digital , Feminino , Fluoroscopia , Humanos , Pessoa de Meia-Idade , Doses de Radiação , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
PURPOSE: Percutaneous nephrolithotomy access may be technically challenging and result in significant radiation exposure. In an attempt to reduce percutaneous nephrolithotomy radiation exposure, a novel technique combining ultrasound and direct ureteroscopic visualization was developed and reviewed. MATERIALS AND METHODS: Ureteroscopy without fluoroscopy was used to determine the optimal calyx for access, which was punctured with a Chiba needle under percutaneous ultrasound guidance. Next a wire was passed into the collecting system and ureteroscopically pulled into the ureter using a basket. Tract dilation and sheath and nephrostomy tube placement were performed under direct ureteroscopic visualization. Twenty consecutive patients undergoing this novel technique were reviewed and compared to 20 matched patients treated with conventional percutaneous nephrolithotomy. Mann-Whitney U and Pearson chi-square tests were used for comparisons with p <0.05 considered significant. RESULTS: Using this novel technique mean fluoroscopy access time was 3.5 seconds (range 0 to 27.9) and mean total fluoroscopic time was 8.8 seconds (range 0 to 47.1). Mean operative time was 232 minutes (range 87 to 533), estimated blood loss was 111 ml, the stone-free rate was 65% and the complication rate was 25%. Compared to 20 matched conventional percutaneous nephrolithotomy cases, there was no difference in operative time (p=0.76), estimated blood loss (p=0.64), stone-free rate (p=0.50) or complications (p=1.00). However, the novel technique resulted in a significant reduction in fluoroscopy access time (3.5 vs 915.5 seconds, p <0.001) and total fluoroscopy time (8.8 vs 1,028.7 seconds, p <0.001). CONCLUSIONS: This study demonstrates the feasibility of combined ultrasound and ureteroscopic assisted access for percutaneous nephrolithotomy. A greater than 99% reduction in fluoroscopy time was achieved using this technique.
Assuntos
Nefrolitotomia Percutânea/métodos , Ultrassonografia de Intervenção , Ureteroscopia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Exposição à Radiação/prevenção & controle , Estudos RetrospectivosRESUMO
Advances in computed tomography (CT) angiography have increased the sensitivity and specificity of detecting small branch arterial injuries in the extremities of trauma patients. However, it is unclear whether these patients should undergo surgery, angioembolization, or conservative watchful waiting. We hypothesized that uncomplicated small arterial branch injuries can be managed successfully with watchful waiting. A 10-year retrospective review of extremity CT angiograms with search findings of arterial "active extravasation" or "pseudoaneurysm" was performed at a level 1 county trauma center. Subgroup analysis was performed on those with isolated extremity injury and those with concurrent injuries. A total of 31 patients had CT-detected active extravasation (84 %) or pseudoaneurysm (16 %), 71 % of which were isolated vascular injuries. Of the patients evaluated, 71 % (n = 22) were managed with watchful waiting, 19 % (n = 6) with angioembolization, and 10 % (n = 3) with surgery. Watchful waiting complications included progression to alternative treatment (n = 1) and blood transfusions (n = 2). Complications of surgery included the inability to find active bleeding (n = 1) and postoperative psychosis (n = 1). Complications of angioembolization were limited to a postprocedure blood transfusion (n = 1). Patients with isolated vascular injuries had an average length of stay of 2.9 days, with management averages of the following: 2.7 days with watchful waiting (n = 16), 3.3 days with angioembolization (n = 3), and 3.7 days with surgery (n = 3). CT angiography has greatly increased the reported incidence of traumatic arterial injury in the extremity. We propose that small branch arterial injuries in the extremities can be managed successfully with watchful waiting and do not often require immediate embolization.
Assuntos
Traumatismos do Braço/diagnóstico por imagem , Traumatismos da Perna/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Lesões do Sistema Vascular/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Traumatismos do Braço/terapia , Tomada de Decisões , Embolização Terapêutica , Feminino , Humanos , Traumatismos da Perna/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/terapia , Conduta ExpectanteAssuntos
Angioplastia com Balão/instrumentação , Oclusão de Enxerto Vascular/terapia , Veia Ilíaca/transplante , Transplante de Fígado/efeitos adversos , Veias Mesentéricas/cirurgia , Veia Porta/cirurgia , Stents Metálicos Autoexpansíveis , Doenças Vasculares/cirurgia , Enxerto Vascular/efeitos adversos , Ligas , Constrição Patológica , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Masculino , Veias Mesentéricas/diagnóstico por imagem , Veias Mesentéricas/fisiopatologia , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Desenho de Prótese , Falha de Tratamento , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/etiologia , Doenças Vasculares/fisiopatologia , Grau de Desobstrução Vascular , Adulto JovemRESUMO
PURPOSE: To evaluate radiation dose reduction in patients undergoing transarterial chemoembolization with the use of a new image acquisition and processing platform. MATERIALS AND METHODS: Radiation-dose data were obtained from 176 consecutive chemoembolization procedures in 135 patients performed in a single angiography suite. From January 2013 through October 2013, 85 procedures were performed by using our institution's standard fluoroscopic settings. After upgrading the x-ray fluoroscopy system with an image acquisition and processing platform designed to reduce image noise and reduce skin entrance dose, 91 chemoembolization procedures were performed from November 2013 through December 2014. Cumulative dose-area product (CDAP), cumulative air kerma (CAK), and total fluoroscopy time were recorded for each procedure. Image quality was assessed by three interventional radiologists blinded to the x-ray acquisition platform used. RESULTS: Patient radiation dose indicators were significantly lower for chemoembolization procedures performed with the novel imaging platform. Mean CDAP decreased from 3,033.2 dGy·cm(2) (range, 600.3-9,404.1 dGy·cm(2)) to 1,640.1 dGy·cm(2) (range, 278.6-6,779.9 dGy·cm(2); 45.9% reduction; P < .00001). Mean CAK decreased from 1,445.4 mGy (range, 303.6-5,233.7 mGy) to 971.7 mGy (range, 144.2-3,512.0 mGy; 32.8% reduction; P < .0001). A 20.3% increase in mean total fluoroscopy time was noted after upgrading the imaging platform, but blinded analysis of the image quality revealed no significant degradation. CONCLUSIONS: Although a small increase in fluoroscopy time was observed, a significant reduction in patient radiation dose was achieved by using the optimized imaging platform, without image quality degradation.
Assuntos
Angiografia/instrumentação , Quimioembolização Terapêutica/instrumentação , Fluoroscopia/instrumentação , Doses de Radiação , Proteção Radiológica/instrumentação , Radiografia Intervencionista/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
PURPOSE: We propose a compressed-sensing (CS) technique based on magnitude image subtraction for high spatial and temporal resolution dynamic contrast-enhanced MR angiography (CE-MRA). METHODS: Our technique integrates the magnitude difference image into the CS reconstruction to promote subtraction sparsity. Fully sampled Cartesian 3D CE-MRA datasets from 6 volunteers were retrospectively under-sampled and three reconstruction strategies were evaluated: k-space subtraction CS, independent CS, and magnitude subtraction CS. The techniques were compared in image quality (vessel delineation, image artifacts, and noise) and image reconstruction error. Our CS technique was further tested on seven volunteers using a prospectively under-sampled CE-MRA sequence. RESULTS: Compared with k-space subtraction and independent CS, our magnitude subtraction CS provides significantly better vessel delineation and less noise at 4× acceleration, and significantly less reconstruction error at 4× and 8× (P < 0.05 for all). On a 1-4 point image quality scale in vessel delineation, our technique scored 3.8 ± 0.4 at 4×, 2.8 ± 0.4 at 8×, and 2.3 ± 0.6 at 12× acceleration. Using our CS sequence at 12× acceleration, we were able to acquire dynamic CE-MRA with higher spatial and temporal resolution than current clinical TWIST protocol while maintaining comparable image quality (2.8 ± 0.5 vs. 3.0 ± 0.4, P = NS). CONCLUSION: Our technique is promising for dynamic CE-MRA.
Assuntos
Artérias/fisiologia , Compressão de Dados/métodos , Gadolínio , Interpretação de Imagem Assistida por Computador/métodos , Imageamento Tridimensional/métodos , Angiografia por Ressonância Magnética/métodos , Compostos Organometálicos , Técnica de Subtração , Algoritmos , Artérias/anatomia & histologia , Velocidade do Fluxo Sanguíneo/fisiologia , Meios de Contraste , Humanos , Aumento da Imagem/métodos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: Most studies recommend repair of renal artery aneurysms (RAAs) >2 cm in diameter in asymptomatic patients, but other studies have suggested that their natural history may be more benign. We hypothesized that rupture and death in patients with asymptomatic RAAs is low and that current recommendations for RAA treatment at 2 cm may be too aggressive. METHODS: Retrospective review of all RAAs treated at a tertiary care medical center from 2002 to 2012. RESULTS: Fifty-nine RAA were identified in 40 patients (mean age at diagnosis, 56 years; male:female ratio, 17:23); 31 were saccular, 8 were fusiform, and 5 were bilobed. Twenty-nine patients were asymptomatic; the remainder of patients presented with hematuria (n = 4), abdominal pain (n = 3), difficult-to-control hypertension (n = 3), or flank pain (n = 2). Aneurysm location included the main renal artery bifurcation (n = 35), main trunk (n = 7), primary branch (n = 6), pole artery (n = 6), and secondary branch (n = 1). Operative management of RAAs included vein patch (n = 6), prosthetic patch (n = 4), primary repair (n = 3), plication (n = 1), patch and implantation (n = 1), and ex vivo repair (n = 1). Eight asymptomatic RAAs were treated surgically (mean RAA diameter = 2.4 ± 0.1 cm, range, 2-3 cm), with the remaining 33 asymptomatic RAAs being managed conservatively (mean RAA diameter = 1.4 ± 0.1 cm, range, 0.6-2.6 cm). Mean hospital length of stay was 4 days, with no late postoperative complications and 0% mortality. Non-operated patients were followed for a mean of 36 ± 9 months, with no late acute complications and 0% mortality. Mean RAA growth rate of patients with multiple imaging studies was 0.60 ± 0.16 mm/y. CONCLUSIONS: The rate of aneurysm rupture and death in our untreated RAA patients is zero, the growth rate is 0.60 ± 0.16 mm/y, and there were no adverse outcomes in asymptomatic RAAs >2 cm that were observed. We may currently be too aggressive in treating asymptomatic RAAs.
Assuntos
Aneurisma/terapia , Seleção de Pacientes , Artéria Renal/cirurgia , Procedimentos Desnecessários , Procedimentos Cirúrgicos Vasculares , Dor Abdominal/etiologia , Aneurisma/complicações , Aneurisma/diagnóstico , Aneurisma/mortalidade , Aneurisma Roto/etiologia , Doenças Assintomáticas , Comorbidade , Feminino , Dor no Flanco/etiologia , Hematúria/etiologia , Humanos , Hipertensão/etiologia , Los Angeles , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Procedimentos Desnecessários/normas , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/normasRESUMO
Objective: To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS). Methods: This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test. Results: There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007). Conclusion: An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.
RESUMO
Internal iliac artery aneurysms (IIAAs), isolated or associated with abdominal aortic aneurysms, are at rupture risk with growth. Treatment is recommended when symptomatic or greater than 3 cm. Surgical or endovascular therapy should exclude the arterial origin and outflow branches. If all outflow branches are not completely embolized, an endoleak can develop, pressurizing the sac leading to growth and rupture. Accessing the arteries involved can be technically challenging and understanding potential targets is critical. We describe two percutaneous approaches for treatment: percutaneously accessing the sac from an anterior trans-iliopsoas approach and percutaneously accessing the gluteal artery from a posterior approach.