Patient presentation and management of labial ulceration following uterine artery embolization.

Uterine artery embolization is a safe and effective procedure for the treatment of symptomatic uterine fibroids. Nontarget embolization of adjacent internal iliac artery branches is a reported complication of uterine artery embolization. The following report describes the presentation and management of ulcerations of the labium minora due to nontarget embolization of the internal pudendal artery.

Endovascular repair of carotid artery aneurysms following carotid endarterectomy.

Aneurysm of the carotid artery following endarterectomy is a rare entity that historically has required reoperation. Endovascular deployment of a covered stent can theoretically exclude an aneurysm while minimizing the risks seen with reoperation. Herein, we review the scientific literature on this evolving technique and report an additional case involving successful treatment of an aneurysm that developed following remote endarterectomy.

The changing roles of radiologists, cardiologists, and vascular surgeons in percutaneous peripheral arterial interventions during a recent five-year interval.

PURPOSE: This study aimed to determine the relative roles of radiologists, cardiologists, vascular surgeons, and other physicians in performing percutaneous peripheral arterial interventions and how these roles have changed over a recent 5-year period. METHODS AND MATERIALS: The authors reviewed the Medicare Part B fee-for-service databases between 1997 and 2002 for the Current Procedural Terminology (4th ed.) (CPT-4) surgical procedure codes for percutaneous transluminal angioplasty (PTA) of noncardiac peripheral arteries (six codes), the transcatheter placement of noncardiac intravascular stents (two codes), and endovascular aortic stent graft placement (six codes). Using the Medicare physician specialty codes, procedure volume in each CPT-4 code was determined for radiologists, cardiologists, vascular surgeons, and other physicians. Percentage changes from 1997 to 2002 were calculated for PTA and intravascular stent placement procedures. RESULTS: Between 1997 and 2002, the total Medicare procedure volume in the eight procedure codes relating to PTA and stent placement increased by 95%. In 2002, radiologists performed 72,657 of these procedures, cardiologists 62,901, vascular surgeons 17,895, and other physicians 19,666. Over the 5-year interval, procedure volume among radiologists increased 29%, among cardiologists by 181%, among vascular surgeons by 398%, and among other physicians by 195%. Radiologists' share in the total pool of procedures in 2002 was 42.0% (down from 63.3% in 1997), cardiologists' 36.3% (up from 25.2% in 1997), vascular surgeons' 10.3% (up from 4.0% in 1997), and other physicians' 11.4% (up from 7.5% in 1997). Trend data were not available for endovascular aortic stent graft procedures. CONCLUSION: Between 1997 and 2002, procedure volume in percutaneous peripheral arterial interventions grew at faster rates among cardiologists, vascular surgeons, and other physicians than it did among radiologists. As a result, radiologists' share of this market declined during the interval. However, procedure volume among radiologists continued to grow over the 5 years, and in 2002, they still had the largest share among the four physician specialty groups. Thus, despite the erosion, interventional radiologists still maintain a strong position in this rapidly growing field.

Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata.

Uterine artery embolization (UAE) is assuming an important role in the treatment of women with symptomatic uterine leiomyomata worldwide. The following guidelines, which have been jointly published with the Society of Interventional Radiology in the Journal of Vascular and Interventional Radiology, are intended to ensure the safe practice of UAE by identifying the elements of appropriate patient selection, anticipated outcomes, and recognition of possible complications and their timely address.

Complications of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure: a case-controlled study.

PURPOSE: To evaluate the incidence and types of complications encountered with use of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure in a retrospective case-controlled study. MATERIALS AND METHODS: The authors identified 100 consecutive patients, 15 men and 85 women 21-85 years of age (mean, 50 years), between December 2000 and July 2001 in whom the Closer percutaneous suture-mediated closure device was used during 65 uterine artery embolization (UAE) procedures, 11 hepatic chemoembolization procedures, nine diagnostic angiography procedures, seven peripheral vascular interventions, six visceral arterial interventions, and two thrombolysis procedures. An age-, sex-, and procedure-matched control population was identified in which manual compression was performed. Procedure reports and clinical charts were reviewed for the presence of puncture-site complications, as categorized according to Society of Interventional Radiology reporting standards, and for risk factors and comorbid conditions (hypertension, diabetes, stroke, smoking, and coronary artery disease). Follow-up visits and imaging studies were reviewed for patients with complications. RESULTS: In the Closer group, there were seven device failures, four minor complications, and three major complications. Minor complications included two groin hematomas and two cases of persistent pain at the arteriotomy site. Three major complications consisted of two cases of external iliac artery dissection, one with distal embolization, and one case of common femoral artery (CFA) occlusion and distal embolization. All major complications occurred in women undergoing UAE. One patient required thromboendarterectomy and patch angioplasty to repair the CFA occlusion, as well as amputation of a gangrenous toe. In the manual-compression group, there was one minor complication (a groin hematoma) and no major complications. There were significantly more complications in the Closer group than in the manual compression group (P =.02). CONCLUSIONS: Significantly more complications were associated with use of a percutaneous suture-mediated closure device than with manual compression for arteriotomy-site hemostasis. Major complications and associated morbidity may be seen with use of percutaneous suture-mediated closure devices. In particular, an unexpectedly high frequency of device-related complications was demonstrated in young women undergoing UAE.

Labial necrosis after uterine artery embolization for leiomyomata.

BACKGROUND: Uterine artery embolization is increasingly used as an alternative to myomectomy, hysterectomy, and medical treatment for the management of symptomatic leiomyomata. CASE: A woman with an 18-week-size fibroid uterus who underwent uterine artery embolization developed a 3-cm, exquisitely tender, hypopigmented, necrotic-appearing area on the right labium minus. Spontaneous resolution occurred over 4 weeks. CONCLUSION: Labial necrosis is a possible complication of uterine artery embolization and may be successfully managed with conservative therapy.

II. Uterine fibroid embolization: technical aspects.

Successful superselective catheterization of the uterine artery requires familiarity with female pelvic arterial anatomy, knowledge of effective catheter and guidewire combinations, and a few tricks. A learning curve can be expected for each of these elements, although it is assumed that the operator will already have experience in basic catheter techniques. Safe transcatheter delivery, understanding of embolization end points, and avoidance of nontarget embolization are essential. Equally important are knowledge of the properties of the embolic agents currently available and their indications for use. Uterine fibroid embolization unavoidably results in radiation exposure to the uterus and ovaries, and adherence to meticulous fluoroscopic technique is crucial to keep the absorbed dose as low as possible.

V. Uterine fibroid embolization: management of complications.

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

IV. Uterine fibroid embolization: follow-up.

Patients generally notice some relief of both menorrhagia and mass-effect symptoms during the first few weeks after uterine fibroid embolization (UFE). Shrinkage of the fibroids continues to take place over several months, peaking somewhere between 3 and 6 months, with measurable shrinkage sometimes noted for up to 1 year. The timing of follow-up visits is intended to coincide with the time course of improvement so that diagnostic imaging and intervention can be performed if symptoms worsen or relief does not appear to be on schedule. The amount of shrinkage of fibroids correlates neither with the intensity of immediate postprocedure symptoms or the degree of symptom relief. Affected fibroids undergo hyaline degeneration, a process in which the hard, cellular tumor is replaced by softer, acellular material. A nationwide registry has been constructed for the accumulation of procedural and follow-up data so that success and complication rates can be accurately determined and long-term issues about the durability of UFE and possible side effects can be addressed.

III. Uterine fibroid embolization: pain management.

Conscious sedation and analgesia are integral components of successful uterine fibroid embolization (UFE), both in providing comfort to the anxious patient undergoing an elective procedure and for providing relief of the severe pelvic pain, cramps, and nausea that may result from acute uterine ischemia and the postembolization syndrome that may follow. The agents used are typically those with which interventional radiologists already have extensive experience in the performance of a variety of invasive procedures. Immediate postprocedure care benefits greatly from the use of narcotic delivered via PCA (patient-controlled analgesia) pump. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also particularly useful for treating the pain and cramping caused by UFE and help reduce the amount of narcotic necessary for pain relief during the recovery period. Detailed instructions for the first week of convalescence are necessary to insure comfort and avoid complications.

VI. Uterine fibroid embolization: developing a clinical service.

Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.

Ischemic jejunal stricture following endovascular abdominal aortic aneurysm repair -- a case report.

Endograft repair has rapidly become an alternative to conventional open repair of abdominal aortic aneurysms. Various trials continue to show decreased morbidity when compared to open repair. However, as with any new procedure, complications specifically related to this technique are being described. Herein, we report a case of an isolated ischemic jejunal stricture presenting as a small-bowel obstruction secondary to cholesterol emboli following endograft repair of an abdominal aortic aneurysms.

Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent.

A postoperative superior mesenteric artery pseudoaneurysm that communicates with a pancreatic pseudocyst after aortic surgery is a difficult management problem. Untreated, this condition can lead to exsanguination. Traditional surgical treatment has many potential complications. Endovascular repair has the potential for avoidance of surgical complications. We present the first superior mesenteric artery pseudoaneurysm successfully treated with A polytetrafluorethylene covered stent.