Pre-operative uterine artery embolization before hysterectomy or myomectomy: a single-center review of 53 patients.

PURPOSE: To assess outcomes of planned pre-operative uterine artery embolization (UAE) in patients with uterine fibroids at high risk for bleeding prior to hysterectomy or myomectomy. MATERIALS & METHODS: A retrospective review of 53 consecutive patients who underwent planned UAE followed by surgery from 2004 to 2019 was performed in a subset of patients deemed high risk for bleeding by the referring surgeon due to bulky fibroids and/or adhesions. Characteristics of the largest fibroid, total number of fibroids, embolic agents, estimated blood loss (EBL), complications, and other factors were collected. RESULTS: 53 patients (mean age = 41) had an elective UAE prior to a hysterectomy 24 (45%) or myomectomy 29 (55%). Median interval between UAE & surgery was 21.6 h (range 1.75 h-57 days). Of the myomectomies, 13 (45%) were open, 15 (52%) hysteroscopic and 1 laparoscopic. Mean number of fibroids/patient was 4.1 (SD 1.3), mean fibroid volume was 328 cm3 (range 11-741), and the mean fibroid diameter in longest dimension was 7.4 cm (range 3.2-15). Mean EBL was 90 (SD 99.5 mL). Three (10%) myomectomy patients required blood transfusion. All hysterectomies were via a laparotomy. Mean fibroid volume was 1699 cm3 (range 93-9099 cm3) with a mean maximum diameter of 16.2 cm (range 6.5-29.6) and an average of 2.4 (SD 1.7) fibroids. Mean EBL was 352 (SD 220 mL). Four (17%) hysterectomy patients required an intra- or post-operative blood transfusion. At a mean 1-year follow-up (range 1 month-14 years), 70% of UAE-myomectomy patients and 74% of UAE-hysterectomy patients reported symptom resolution. Three (6%) patients were readmitted: one for osteodiscitis, one wound dehiscence, and one for an infected retained fibroid after myomectomy. CONCLUSION: Planned pre-operative UAE resulted in intraoperative blood loss similar to "all-comer" myomectomy and hysterectomy patients in the literature. Further studies may elucidate which patients would be the best candidates for this staged treatment paradigm.

Effect of computed tomography angiography prior to bronchial embolization on radiation dose and recurrent hemoptysis.

PURPOSE: To investigate whether pre-procedure Computed Tomography Angiography (CTA) improves radiation exposure, procedure complexity, and symptom recurrence after bronchial embolization for massive hemoptysis. MATERIAL AND METHODS: A single-center retrospective review of bronchial artery embolization (BAE) for massive hemoptysis was performed for procedures between 2008 and 2019. Multi-variate analysis was performed to determine the significance of pre-procedure CTA and etiology of hemoptysis on patient radiation exposure (reference point air kerma, RPAK) and rate of recurrent hemoptysis. RESULTS: There were 61 patients (mean age 52.5 years; SD = 19.2 years, and 57.3% male) and CTA was obtained for 42.6% (26/61). Number of vessels selected was a mean of 7.2 (SD = 3.4) in those without CTA and 7.4 (SD = 3.4) in those with CTA (p = 0.923). Mean procedure duration was 1.8 h (SD = 1.6 h) in those without CTA and 1.3 h (SD = 1.0 h) in those with CTA (p = 0.466). Mean fluoroscopy time and RPAK per procedure were 34.9 min (SD = 21.5 min) and 1091.7 mGy (SD = 1316.6 mGy) for those without a CTA and 30.7 min (SD = 30.7 min) and 771.5 mGy (SD = 590.0 mGy) for those with a CTA (p = 0.523, and p = 0.879, respectively). Mean total iodine given was 49.2 g (SD = 31.9 g) for those without a CTA and 70.6 g (SD = 24.9 g) for those with a CTA (p = 0.001). Ongoing hemoptysis at last clinical follow up was 13/35 (37.1%) in those without CTA and 9/26 (34.6%) in those with CTA (p = 0.794). CONCLUSIONS: Pre-procedure CTA did not improve radiation effective dose and symptom recurrence after BAE and is associated with significant increases in total iodine dose.

Management of Pancreatico-duodenal arterio-venous malformation.

PURPOSE: To describe the interventional management and clinical outcome of pancreatico-duodenal arterio-venous malformations (PDAVMs). MATERIAL AND METHODS: Seven patients presenting a PDAVM (6 women, 1 male; mean age: 61) were retrospectively reviewed. Technical, clinical success and complications of embolization and surgical management of symptomatic PDAVMs were assessed. Technical success was defined as a complete occlusion of the PDAVM and clinical success as no clinical symptom or recurrence during follow-up. Patients with asymptomatic PDAVMs were followed clinically, by Doppler ultrasound and CT-angiography. RESULTS: Mean follow-up time was 69 months (15-180). Five symptomatic patients presented with upper gastrointestinal bleeding (n=3), ascites (n=1), and abdominal pain (n=1). Two patients were asymptomatic. The PDAVMs were classified as follow: Yakes I (1), IIIa (2), IIIb (3) and IV (1). Five symptomatic patients were treated with 9 embolization sessions with arterial approach (onyx®, glue, coils) in 7 and venous approach in 2 (plugs, coils, covered stents, STS foam and onyx®). Technical success of embolization was 60% (3/5). Devascularization was incomplete for 2 Yakes IIIB patients. Clinical success of embolization was estimated at 80% (4/5) as one patient required additional surgery (Whipple) because of persistent bleeding. One splenic vein thrombosis was treated successfully by mechanical thrombectomy and heparin. No recurrence occurred during follow-up. No progression was documented in asymptomatic patients. CONCLUSION: Embolization of symptomatic PDAVMs is effective and surgery should be performed in second intention. Complete devascularization is more difficult to obtain in Yakes III PDAVM.

Thyroid Radiofrequency Ablation: Updates on Innovative Devices and Techniques.

Radiofrequency ablation (RFA) is a well-known, effective, and safe method for treating benign thyroid nodules and recurrent thyroid cancers. Thyroid-dedicated devices and basic techniques for thyroid RFA were introduced by the Korean Society of Thyroid Radiology (KSThR) in 2012. Thyroid RFA has now been adopted worldwide, with subsequent advances in devices and techniques. To optimize the treatment efficacy and patient safety, understanding the basic and advanced RFA techniques and selecting the optimal treatment strategy are critical. The goal of this review is to therefore provide updates and analysis of current devices and advanced techniques for RFA treatment of benign thyroid nodules and recurrent thyroid cancers.

Ten frequently asked questions about MRI evaluation of soft-tissue vascular anomalies.

OBJECTIVE: The objective of this article was to address 10 frequently asked questions that radiologists face when planning, performing, and interpreting an MRI study in a patient with a soft-tissue vascular anomaly. CONCLUSION: MRI permits a comprehensive assessment of vascular anomalies. It is important for radiologists to be familiar with the classification and correct nomenclature of vascular anomalies as well as the MRI protocol and distinct imaging findings of the different vascular malformations and tumors.

Extrahepatic pseudoaneurysms and ruptures of the hepatic artery in liver transplant recipients: endovascular management and a new iatrogenic etiology.

PURPOSE: To characterize extrahepatic pseudoaneurysm regarding incidence and etiology and determine the effectiveness of endovascular management. METHODS: A retrospective audit of 1,857 liver transplants in two institutions was performed (1996-2009). Recipients' demographics, clinical presentation, transplant type, biliary anastomosis, and presence of biliary endoprostheses were noted. Pseudoaneurysms were classified into iatrogenic (associated with biliary endoprosthesis or angioplasty) or spontaneous extrahepatic pseudoaneurysms. Spontaneous and iatrogenic pseudoaneurysms were compared for time from transplant, presenting symptoms, location in the arterial anatomy, and 3-month graft survival. Arterial patency and 6-month graft survival were calculated. RESULTS: Twenty pseudoaneurysms were found (1.1 %, 20/1,857): 9 (0.5 % of transplants, 9/1,857) were spontaneous and 11 (0.6 % of transplants, 11/1,857) were "iatrogenic" (due to minimally invasive procedures: 4 angioplasty and 7 biliary endoprostheses). Sixty percent (12/20) underwent endovascular management (4 coil embolization and 8 stent-grafts). Technical success was 83 % (10/12) with a mean arterial patency of 70 % (follow-up mean, 4.9; range, 0-18 months). The 1-, 3-, and 6-month graft survival was 70, 40, and 35 %, respectively. CONCLUSIONS: Due to minimally invasive procedures, posttransplant extrahepatic pseudoaneurysms are no longer an exclusive complication of the transplant surgery itself. Endovascular management is effective to stabilize patients but has not improved historic postsurgical graft survival.

MR imaging of soft-tissue vascular malformations: diagnosis, classification, and therapy follow-up.

Vascular malformations and tumors comprise a wide, heterogeneous spectrum of lesions that often represent a diagnostic and therapeutic challenge. Frequent use of an inaccurate nomenclature has led to considerable confusion. Since the treatment strategy depends on the type of vascular anomaly, correct diagnosis and classification are crucial. Magnetic resonance (MR) imaging is the most valuable modality for classification of vascular anomalies because it accurately demonstrates their extension and their anatomic relationship to adjacent structures. A comprehensive assessment of vascular anomalies requires functional analysis of the involved vessels. Dynamic time-resolved contrast material-enhanced MR angiography provides information about the hemodynamics of vascular anomalies and allows differentiation of high-flow and low-flow vascular malformations. Furthermore, MR imaging is useful in assessment of treatment success and establishment of a long-term management strategy. Radiologists should be familiar with the clinical and MR imaging features that aid in diagnosis of vascular anomalies and their proper classification. Furthermore, they should be familiar with MR imaging protocols optimized for evaluation of vascular anomalies and with their posttreatment appearances. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.315105213/-/DC1.

Endovascular therapy for hepatic artery stenosis and thrombosis following liver transplantation.

PURPOSE: To evaluate the effectiveness of endovascular management of steno-oclusive disease in liver transplants. METHODS: Retrospective review of liver transplant recipients with hepatic artery stenosis (HAS) or thrombosis (HAT) was performed. The HAS group was treated with balloon angioplasty with selective stent placement. The HAT group was treated with catheter-directed thrombolysis. Primary, unassisted, and assisted patency and graft survival rates were calculated. RESULTS: In all, 31 patients were identified (21 males; mean age, 51 years). A total of 25 of 31 (81%) patients had HAS and 6 of 31 (19%) had HAT. Collectively, a total of 35 endovascular procedures were performed to treat HAS in 25 patients. Overall technical success rate was 91%, with 11% major complication rate. Primary-assisted patency rate and graft survival at 6 and 12 months were 87% and 81%, and 76% and 72%, respectively. Only 1 successful thrombolysis of HAT was achieved. CONCLUSION: Endovascular management is effective for HAS but not for HAT.

Treatment of renal artery fibromuscular dysplasia.

Fibromuscular dysplasia is a nonatherosclerotic and noninflammatory disease that can result in stenoses of the renal arteries and hypertension, most commonly affecting middle-aged women. Percutaneous transluminal angioplasty has long been considered the mainstay of therapy and offers high rates of improved or cured hypertension. The disease involves the mid and distal renal arteries and branchpoints and poses endovascular treatment challenges that separate fibromuscular dysplasia from atherosclerotic disease. The development of smaller balloon dilation systems offers safe and highly effective endovascular treatment options for technically difficult lesions. Newer technologies such as cutting balloons also add to the armamentarium of treatment choices, which may be useful in the setting of resistant stenoses. This article focuses on the modern technical considerations in the diagnostic evaluation and endovascular treatment of renal artery fibromuscular dysplasia.

Ultrasound-guided fine-needle aspiration biopsy of thyroid nodules smaller than 5 mm in the maximum diameter: assessment of efficacy and pathological findings.

OBJECTIVE: The aim of this study was to determine the efficacy of the use of an ultrasound-guided fine-needle aspiration biopsy (US-FNAB) to diagnose thyroid nodules smaller than 5 mm in the maximum diameter and to evaluate pathological findings of small thyroid malignancies. MATERIALS AND METHODS: From May 2007 to April 2008, we evaluated the findings of US-FNABs of small thyroid nodules less than 5 mm in the maximum diameter. The cytopathological findings were retrospectively reviewed and the diagnostic performance of the use of an US-FNAB was examined in all patients. RESULTS: Of 201 small thyroid nodules in 180 patients, there were 162 adequate specimens (81%). Among 180 patients, 75 patients underwent thyroid surgery and 50 malignant and 33 benign nodules were identified based on a pathological examination. All small malignant thyroid nodules were identified as papillary thyroid microcarcinomas (PTMCs). There were 34 (55%) true positive, 0 (0%) false positive, 23 (37%) true negative and five (8%) false negative results for malignancy after performing a first US-FNAB in 62 surgically confirmed nodules. The sensitivity (87%), specificity (100%), positive predictive value (100%), negative predictive value (82%), accuracy (92%), false positive rate (0%) and false negative rate (8%) for an US-FNAB were determined. In 23 patients with a primary PTMC, capsular invasion (9%, 2 of 23), a perithyroidal lymph node metastasis (30%, 7 of 23), the rate of multifocality (9%, 2 of 23) and bilaterality (4%, 1 of 23) were also determined. CONCLUSION: An US-FNAB of thyroid nodules smaller than 5 mm in the maximum diameter is an effective diagnostic procedure.

Crisscross-configured dual stent placement for trisectoral drainage in patients with advanced biliary hilar malignancies.

PURPOSE: To evaluate technical success and clinical efficacy of crisscross-configured dual biliary stent implantation in patients with a biliary hilar tumor extending beyond the segmental ducts. MATERIALS AND METHODS: Between January 2002 and December 2006, two metallic stents were placed crossing each other in a hepatic hilum in 42 patients. One stent was placed between one right sectoral duct and the left hepatic duct and the other was placed between another right sectoral duct and the common bile duct. The patients ranged in age from 36 to 83 years (mean, 63.3 y) and included 26 men and 16 women. Technical success, clinical success, complications, and long-term results were analyzed by retrospective review. RESULTS: Stent placement was performed through two right accesses (n = 30), one right and one left access (n = 3), or two right accesses and one left access (n = 6). Successful "trisectoral" drainage was obtained with two stents in 41 patients (98%). In one case of initial technical failure, an additional stent was needed to connect the two previously placed stents. Clinical success was obtained in 34 of the remaining 36 patients (92%). No procedure-related major complication was observed. The median primary stent patency time was 187 days and the median patient survival time was 247 days. CONCLUSIONS: Crisscross-configured dual stent implantation is a feasible, safe, and effective method to maximize hepatic drainage with a minimal number of stents in patients with advanced biliary hilar malignancy.

T-configured dual stent placement in malignant biliary hilar duct obstructions with a newly designed stent.

PURPOSE: To evaluate the technical success and clinical efficacy of T-configured dual stent placement in the management of malignant biliary hilar duct obstructions with a newly designed stent. MATERIALS AND METHODS: Between January 2001 and July 2002, 57 patients with malignant biliary hilar duct obstruction were treated with percutaneous transhepatic placement of two self-expandable metallic endoprostheses in a T configuration with use of a newly designed stent. The patients ranged in age from 46 to 85 years and included 37 men and 20 women. RESULTS: Stent placement with two endoprostheses was successful in all patients. The mean survival and stent patency times were 193.6 days (range, 7-442 days) and 170.3 days (range, 7-305 days), respectively. There were no statistical differences in age, sex, or Bismuth type. CONCLUSION: T-configured dual stent placement with a newly designed stent is simple, safe, and reliable in achieving bilateral internal bile drainage in patients with malignant biliary hilar obstructions.