Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization.

PURPOSE: The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery. METHODS: Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity. RESULTS: All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%. CONCLUSION: Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

Percutaneous sodium tetradecyl sulfate sclerotherapy for peripheral venous vascular malformations: a single-center experience.

PURPOSE: To evaluate the efficacy, safety, and long-term outcomes of percutaneous sodium tetradecyl sulfate (STS)sclerotherapy for peripheral venous vascular malformations (VVMs). MATERIALS AND METHODS: A retrospective review of a prospectively compiled database was performed to identify patients with a VVM who were referred from 1997 to 2004. Of the 132 patients identified, 78 underwent sclerotherapy. Six of the 78 patients were lost to follow-up. Of the remaining 72 patients (24 male and 48 female patients; mean age, 31.7 years; age range, 14-62 years), 42 (58%) had lower limb VVMs, 19 (26%) had upper limbVVMs, and nine (12%) had truncal and/or central VVMs. Two patients (2.8%) had multifocal lesions. Seven of the 72 patients (9.7%) had Klippel-Trénauney syndrome. Treatment response was assessed clinically and by means of lesion size measurement with magnetic resonance (MR) imaging. RESULTS: A total of 226 treatment sessions were performed (mean, 3.1 sessions per patient; range, 1-13 sessions). The mean follow-up was 41 months (range, 21-84 months). After treatment, 11 patients (15%) became asymptomatic, 20(28%) rated the response to therapy as good, 17 (24%) improved, 20 (28%) were unchanged, and four (5.6%) worsened.Thirty-five patients underwent MR imaging before and after treatment. The size of the VVM was seen to decrease in19 patients (54%), be unchanged in 11 (31%), and increase in five (14%). A reduction in lesion size at MR imaging did not necessarily correlate with a positive clinical response. Overall, patients with infiltrative lesions had a poorer outcome than did those with localized lesions. There were no major complications and seven minor complications(3.1% per session, 9.7% per patient). CONCLUSIONS: An improvement in symptoms was observed in 70% of the patients with VVMs treated with percutaneous STS. Although the treatment is safe, complete cure is unusual and multiple treatment sessions are almost always required.

Venous aneurysms in autogenous hemodialysis fistulas: is there an association with venous outflow stenosis.

PURPOSE: To determine whether patients with venous aneurysms in their arteriovenous fistulas (AVFs) have associated venous outflow stenoses. MATERIALS AND METHODS: A retrospective study was performed, which included all patients presenting with dysfunction and had venous aneurysms in their AVFs. Patient's medical records and imaging studies were examined and data collected including access characteristics, patient demographics and imaging findings. Data were analyzed using Fisher's exact test. RESULTS: A total of 89 patients (58 men, 31 women; mean age 60) presented for intervention related to access dysfunction with incident venous aneurysms over the study period. Of the 89 patients with venous aneurysms (mean diameter 2.3 cm) of their AVF's, 69 (78%) patients had an associated venous outflow stenosis. The stenoses were present most commonly in the outflow cephalic vein (57%), followed by the cephalic arch (20%), brachiocephalic vein (10%) and subclavian vein (6%). Outflow stenoses in AVFs with venous aneurysms were observed in 87% of brachiocephalic AVFs, 60% of radiocephalic AVFs and 80% of brachiobasilic AVFs. Brachiocephalic AVFs with venous aneurysms were significantly more likely to have an associated outflow stenosis than radiocephalic AVFs with venous aneurysms (P=0.007). AVFs with outflow stenosis were on average 1502 days old while AVFs without outflow stenosis were on average 2351 days old, which was a statistically significant difference (P=0.031). No statistically significant differences were observed for sex and side of the fistula. CONCLUSIONS: Outflow stenosis was observed to be associated with venous aneurysms in AVFs with a more statistically significant association in brachiocephalic AVFs compared to other AVFs.

Patency of femoral tunneled hemodialysis catheters and factors predictive of patency failure.

PURPOSE: To determine the patency rates of and factors associated with increased risk of patency failure in patients with femoral vein tunneled hemodialysis catheters. METHODS: All femoral tunneled catheter insertions from 1996 to 2006 were reviewed, during which time 123 catheters were inserted. Of these, 66 were exchanges. Patients with femoral catheter failure versus those with femoral catheter patency were compared. Confounding factors, such as demographic and procedural factors, were incorporated and assessed using univariate and multivariable Cox proportional hazards regression analyses. RESULTS: Mean catheter primary patency failure time was 96.3 days (SE 17.9 days). Primary patency at 30, 60, 90, and 180 days was 53.8%, 45.4%, 32.1%, and 27.1% respectively. Crude rates of risk of catheter failure did not suggest a benefit for patients receiving catheters introduced from one side versus the other, but more cephalad location of catheter tip was associated with improved patency. Multivariate analysis showed that patients whose catheters were on the left side (p = 0.009), were of increasing age at the time of insertion (p = 0.002) and that those who had diabetes (p = 0.001) were at significantly greater risk of catheter failure. The catheter infection rate was 1.4/1000 catheter days. CONCLUSION: Patients who were of a more advanced age and had diabetes were at greater risk of femoral catheter failure, whereas those who received femoral catheters from the right side were less at risk of catheter failure.

Risk of intrauterine infectious complications after uterine artery embolization.

PURPOSE: To identify risk factors for the development of intrauterine infection following uterine artery embolization. MATERIALS AND METHODS: A retrospective review of uterine artery embolizations (UAE) performed for the treatment of symptomatic fibroids from January 2000 to July 2003 was conducted. With logistic regression and the Fisher exact test, multiple variables were analyzed as predictors for intrauterine infectious complications requiring medical and/or surgical therapy, including the use of preprocedural antibiotics, embolic agent used, quantity of embolic material, location of fibroids (submucosal, nonsubmucosal), and size and location of the dominant fibroid. RESULTS: A total of 414 UAE procedures were performed in 410 patients with a technical success rate of 99%. Average age of the patient cohort was 42.8 years (SD, 5.8 years). One hundred forty-eight patients (36.1%) had submucosal fibroids or fibroids projecting submucosally, 262 patients (63.9%) had nonsubmucosal fibroids. Intrauterine infectious complications requiring intravenous antibiotic therapy and/or surgery occurred in five patients (1.2%). A total of five infectious complications requiring therapy occurred in the submucosal group (3.4%) and none in the nonsubmucosal group. Patients within the submucosal group were more likely to develop intrauterine infectious complications than patients with nonsubmucosal fibroids based on univariate analysis (P = .006) but with logistic regression, the association was not significant (P = .079). No significant difference with embolic agent, quantity of embolic particles, use of preprocedure antibiotics, or size of or location of the dominant fibroid was found. CONCLUSION: No specific risk factor for intrauterine infection following UAE was identified in this study. Infection after UAE is rare and appears to be a sporadic occurrence. Nevertheless, close surveillance is warranted in all women following UAE given the potential morbidity of this complication.