Long-term quality of life assessment among patients undergoing uterine fibroid embolization.

OBJECTIVE: The purpose of this study was assessment of the long-term outcome of fibroid-associated quality of life among patients treated with uterine fibroid embolization. MATERIALS AND METHODS: A retrospective follow-up cohort study included all patients described in a 2006 publication. Analysis was performed with a questionnaire consisting of 49 questions about six topics. Assessment was focused on comparing symptoms and quality of life in long-term follow-up. RESULTS: The analysis was based on questionnaires completed by 39 patients. The median follow-up period was 7 years (interquartile range, 1.5 years). Uterine fibroid embolization led to a reduction of bleeding symptoms in 89.7% of the patients, pain in 78.9%, bulk-related symptoms in 89.5%, fatigue in 76.9%, limitations of social life in 92.9%, and depression in 78.6%. The median impairment scores for bleeding and pain decreased significantly from 7 to 0 and from 5 to 0 (both p < 0.001). The general quality-of-life index increased significantly from 4.5 to 9 (p < 0.001). In the long term, there was no significant difference in parameters assessed compared with the midterm follow-up findings. Six patients (15.4%) underwent hysterectomy an average of 32.1 months after intervention. Thirty-two patients (82.1%) continued to be satisfied with the intervention, and 30 patients (76.9%) answered that they would recommend uterine fibroid embolization to other patients. CONCLUSION: Uterine fibroid embolization seems to lead to notable long-term relief of fibroid-associated symptoms. In comparison with the midterm results, long-term outcome shows a clear continuance of improvement in general quality of life.

Endovascular and conventional treatment of thoracic aortic aneurysms: a comparison of costs.

BACKGROUND: The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms. METHODS: Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient. RESULTS: Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 euros considering 1.7 stent-grafts per patient and including 5900.00 euros (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 euros was calculated. Days of care accounted for 31.230.00 euros and total costs of 50.764.12 euros were calculated. The difference between total costs of the two procedures was 12.543.14 euros. CONCLUSIONS: Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.

Assessment of intima-media thickness of carotid arteries: evaluation of an automated computer software.

INTRODUCTION: The aim of this study was to evaluate the feasibility and accuracy of commercially available software directly implemented on the ultrasound scanner for automated measurement of the intima-media thickness (IMT) of the common carotid artery on source images. MATERIALS AND METHODS: Measurements were performed on a GE Vivid 3 ultrasound scanner. First, inter- and intraobserver correlations were assessed for the automated and the manual measurements. Second, the correlation between automated and manual measurements was assessed in 199 asymptomatic patients with a mean age of 30 years (range 20-41 years). RESULTS: The measurement was feasible in all patients and a standard configuration with optimum quality was determined. The inter- and intraobserver correlations obtained using the automated software were excellent and slightly inferior to the manual measurements. The correlation of the automated and manual measurements was significant (r = 0.86; P < 0.01) and the mean difference between both measurements was low (0.023 +/- 0.034 mm). CONCLUSIONS: The software allowed an efficient and quick measurement by providing at the same time comparable results to the manual measurement and a better inter- and intraobserver variability.

CTA quantification of internal carotid artery stenosis: application of luminal area vs. luminal diameter measurements and assessment of inter-observer variability.

BACKGROUND AND PURPOSE: In contrast to digital subtraction angiography (DSAdia), computed tomography angiography (CTA) provides exact delineation of the perfused lumen in the axial plane, thus allowing luminal (CTAdia) as well as cross-sectional area (CTAarea) internal carotid artery stenosis (ICAS) assessment. The purposes of the present study were to correlate CTAdia and CTAarea with DSAdia and to assess the inter-observer variabilities of both CTA techniques. METHODS: In a retrospective analysis, CTA images were reviewed by two observers and ICAS was assessed according to North American Symptomatic Carotid Endarterectomy Trial applying CTAdia and CTAarea. DSAdia was assessed by a third observer. RESULTS: Based on 54 consecutive patients (40 males [74.1%] and 14 females [25.9%]; median age 73.3 years), ICAS percentages of CTAdia and CTAarea revealed significant correlations with DSAdia (r= 0.79-0.87, all P<.001) with median differences in the range of +8% to -6%. Inter-observer agreement was moderate for CTAdia (kappa= 0.60) and excellent for CTAarea (kappa= 0.86). Sensitivity of CTAarea for the detection of ICAS >70% was 100% for both observers, corresponding results for CTAdia were 97.1% and 71.4%, respectively, using DSAdia as the gold standard. CONCLUSION: CTAarea assessment of ICAS correlates well with the results of DSAdia and provides an excellent sensitivity for the detection of ICAS >70% with superior inter-observer agreement compared to CTAdia.

Mid- and long-term quality-of-life assessment in patients undergoing uterine fibroid embolization.

OBJECTIVE: Our objective was to assess the mid- and long-term outcomes concerning fibroid-specific and fibroid-associated quality of life in patients treated by uterine fibroid embolization. MATERIALS AND METHODS: A retrospective cohort study was performed, including consecutive patients with a minimum follow-up of 1 year. Analysis was performed by a questionnaire consisting of 49 questions about six topics: baseline characteristics, preinterventional status, diagnostic workup and treatment planning, periinterventional period and procedure-related quality of life, follow-up, and general satisfaction. RESULTS: The analysis was performed based on questionnaires from 53 (85.5%) of 62 patients. The mean follow-up was 3.0 +/- 1.0 (SD) years (range, 1.0-5.0 years). Uterine fibroid embolization led to a reduction of bleeding symptoms in 79.2% of patients (n = 48 before uterine fibroid embolization; n = 10 after uterine fibroid embolization), pain in 81.5% (n = 27; n = five, respectively), bulk-related symptoms in 78.6% (n = 14; n = three, respectively), urinary dysfunction in 60% (n = 10; n = four, respectively), sexual dysfunction in 71.4% (n = seven; n = two, respectively), fatigue in 62.5% (n = 24; n = nine, respectively), limitations in social life in 88.2% (n = 17; n = two, respectively), and a depressed mood in 89.5% (n = 19; n = two, respectively). The median impairment score for bleeding and pain decreased significantly from 6 to 0 and from 4 to 0, respectively (both p < 0.001). The general quality-of-life index increased significantly from 6 to 9 (p < 0.001). Forty-two (79.2%) patients judged the result as very satisfactory and would highly recommend uterine fibroid embolization to other patients. CONCLUSION: Uterine fibroid embolization leads to an impressive mid- and long-term improvement of all investigated physical and psychological fibroid-related and fibroid-associated symptoms and significantly improves women's health-related quality of life.

Endografting increases total volume of AAA repairs but not at the expense of open surgery: experience in more than 1000 patients.

PURPOSE: To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. METHODS: A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. RESULTS: While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). CONCLUSIONS: The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

MRA versus DSA in the assessment of occlusive disease in the aortic arch vessels: accuracy in detecting the severity, number, and length of stenoses.

PURPOSE: To compare the diagnostic accuracy of contrast-enhanced magnetic resonance angiography (MRA) to that of digital subtraction angiography (DSA) in the detection, grading, and measurement of atherosclerotic stenoses involving the aortic arch arteries. METHODS: The MRA and DSA studies from 28 patients (16 women; mean age 61.6 years, range 24-83) being evaluated for possible aortic arch vessel disease were examined. The aortic arch vasculature was divided into 9 segments; within each segment, the presence and severity of stenotic or occlusive disease was determined based on a 5-point scale. In addition, stenosis length and distance to the branch were measured in 5-mm increments. Image quality was assessed using a 5-point scale. The accuracy, sensitivity, and specificity values, as well as the positive and negative predictive values in MRA's identification of lesions, were evaluated in comparison to DSA. RESULTS: In 28 patients, 189 segments were assessed by both methods. Of these, 173 were correctly rated by MRA, resulting in an accuracy of 91.5%. The accuracy dropped slightly to 86.5% when 11 "not assessable" lesions were included. Sensitivity and specificity for severity measurement were 88.5% and 95.6%, respectively. In 39 of 45 lesions, stenosis length measurements were identical by both methods, but there was a difference of 0.5 cm each in 6 lesions. CONCLUSIONS: MRA as compared to DSA shows high accuracy in the detection and grading of lesions involving the aortic arch vessels. The noninvasive nature of this method recommends its use for screening, treatment planning, and follow-up in known or suspected arterial disease in aortic arch arteries.

Permanent transarterial embolization of neuroendocrine metastases of the liver using cyanoacrylate and lipiodol: assessment of mid- and long-term results.

OBJECTIVE: The purpose of our study was to assess the results of hepatic artery embolization using N-butyl-2-cyanoacrylate and ethiodized oil for the treatment of small-bowel neuroendocrine metastases to the liver as part of a multimodality protocol for the treatment of liver metastases from neuroendocrine small-bowel tumors. MATERIALS AND METHODS: Twenty-three patients underwent permanent embolization of the hepatic artery using cyanoacrylate and Lipiodol for treatment of liver metastases after radical resection of small-bowel neuroendocrine tumors. All patients received additional treatment including somatostatin, and most patients received interferon as well. Cumulative survival rates were estimated using the Kaplan-Meier method. RESULTS: Overall, 75 embolizations (range, 1-10; mean, 3.3) were performed. Median survival time was 69 months, and the estimated cumulative survival rates reached 95.7% and 65.4% for 1 and 5 years, respectively. Two deaths (8.7%) occurred within 1 month of treatment, and one patient experienced a vascular complication at the time of embolization. CONCLUSION: Permanent embolization of hepatic arteries as part of a multimodality treatment protocol is beneficial in long-term follow-up for patients with metastasized small-bowel neuroendocrine tumors. The use of cyanoacrylate as an embolic agent is safe and effective.