Visceral and renal artery aneurysms: a pictorial essay on endovascular therapy.

Visceral artery aneurysms (VAAs), which were once considered uncommon, are now being diagnosed with increasing frequency, a fact that reflects the routine use of computed tomography (CT), magnetic resonance imaging, and ultrasonography. Diagnostic radiology plays a major role in the detection and characterization of VAAs. Cross-sectional imaging can help exclude aneurysm rupture, which requires emergent treatment. CT angiography or catheter angiography can clearly depict the aneurysm and help identify other aortic, visceral, or peripheral aneurysms. Most important, radiologic examination can help determine the adequacy of the collateral blood supply to the vascular bed distal to the aneurysm, information that is essential prior to the initiation of endovascular treatment. Advances in endovascular therapy have allowed interventional radiologists to contribute to the management of VAAs. Coil embolization or covered stent placement can now be used to treat patients with aneurysms whose size or location would make a surgical approach problematic, as well as patients in whom surgery is considered to pose considerable risk.

Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta.

BACKGROUND: Placenta accreta/percreta is a leading cause of third trimester hemorrhage and postpartum maternal death. The current treatment for third trimester hemorrhage due to placenta accreta/percreta is cesarean hysterectomy, which may be complicated by large volume blood loss. PURPOSE: To determine what role, if any, prophylactic temporary balloon occlusion and transcatheter embolization of the anterior division of the internal iliac arteries plays in the management of patients with placenta accreta/percreta. METHODS: The records of 28 consecutive patients with a diagnosis of placenta accreta/percreta were retrospectively reviewed. Patients were divided into two groups. Six patients underwent prophylactic temporary balloon occlusion, followed by cesarean section, transcatheter embolization of the anterior division of the internal iliac arteries and cesarean hysterectomy (n = 5) or uterine curettage (n = 1). Twenty-two patients underwent cesarean hysterectomy without endovascular intervention. The following parameters were compared in the two groups: patient age, gravidity, parity, gestational age at delivery, days in the intensive care unit after delivery, total hospital days, volume of transfused blood products, volume of fluid replacement intraoperatively, operating room time, estimated blood loss, and postoperative morbidity and mortality. RESULTS: Patients in the embolization group had more frequent episodes of third trimester bleeding requiring admission and bedrest prior to delivery (16.7 days vs. 2.9 days), resulting in significantly more hospitalization time in the embolization group (23 days vs. 8.8 days) and delivery at an earlier gestational age than in those in the surgical group (32.5 weeks). There was no statistical difference in mean estimated blood loss, volume of replaced blood products, fluid replacement needs, operating room time or postoperative recovery time. CONCLUSION: Our findings do not support the contention that in patients with placenta accreta/percreta, prophylactic temporary balloon occlusion and embolization prior to hysterectomy diminishes intraoperative blood loss.

Percutaneous gastrostomy for treating dilatation of the bypassed stomach after bariatric surgery for morbid obesity.

OBJECTIVE: Retrospective analysis was performed to determine the safety and effectiveness of percutaneous gastrostomy for treating distention of the bypassed stomach after gastric bypass for morbid obesity. MATERIALS AND METHODS: Eight patients with morbid obesity and Roux-en-Y gastric bypass underwent percutaneous radiologic gastrostomy for postoperative decompression of the bypassed stomach. Four patients underwent gastrostomy on the fourth day after surgery: two in the early postoperative period (< or = 30 days after surgery) and two in the late postoperative period (6, 11 months after the procedure). Procedures were performed using combinations of fluoroscopic, CT, and sonographic guidance. T-tacks and a variety of locking pigtail drainage catheters were placed in seven patients. RESULTS: Gastrostomy placement was technically successful in all patients. Seven of eight patients experienced resolution of symptoms. Gastrostomy catheters were in place for a mean of 31 days. Two complications occurred. Periprocedural peritonitis in one patient with underlying small-bowel obstruction required surgical intervention. One wound infection was treated with antibiotics and local wound care. No catheters became dislodged or obstructed. Four patients treated during the early postoperative period had resolution of symptoms after tube placement and recovered uneventfully. Three of four patients presenting during the intermediate or late postoperative periods had temporary resolution of symptoms, but all eventually required surgical intervention. CONCLUSION: In the absence of complete small-bowel obstruction, percutaneous radiologic gastrostomy provides safe and effective decompression of the excluded gastric remnant after Roux-en-Y gastric bypass. Gastrostomy tube placement after the early postoperative period is temporizing, with surgical intervention eventually required.