An Academic Tertiary Referral Center's Experience with a Vascular Surgery-Based Uterine Artery Embolization Program.

BACKGROUND: Despite growing endovascular experience within the vascular surgery community, some catheter-based interventions-such as uterine artery embolization (UAE)-remain outside the clinical scope of most vascular surgeons, owing in part to established referral patterns and limited awareness among referring colleagues. We present our experience with a vascular surgery-based, multidisciplinary UAE program at an academic tertiary referral center. METHODS: In a collaborative effort between vascular surgeons and gynecologists, a pelvic vascular disease program has been established to provide palliative, prophylactic, and therapeutic embolizations including, but not limited to, UAE. For UAE, inclusion criteria are women over the age of 18 years with symptomatic uterine fibroids demonstrated on magnetic resonance imaging and a negative endometrial biopsy. Exclusion criteria are desire for future pregnancy and previous embolization(s). Technique and perioperative protocol is presented. Data including symptom resolution, reintervention rates, and complications were prospectively gathered and retrospectively reviewed. RESULTS: Over an 18-month period, 30 patients with symptomatic fibroids were referred for potential UAE. Five patients were excluded because of uncertainty about future pregnancy wishes (4) and prior embolization (1). Twenty-four bilateral and 2 unilateral UAEs were performed (mean age, 46.3 years [range 28-53 years]). Presenting symptoms were pelvic and abdominal pain (25), cramps (25), menorrhagia (25), dysmenorrhea (25), urinary frequency (12), and dyspareunia (5). Technical success, defined as successful microcatheterization of uterine arteries and delivery of a particulate liquid embolic agent (embospheres, 500-700 microns), was 100%. There were no perioperative or delayed complications. Twenty-one patients (87.5%) reported complete symptomatic relief without further intervention at the time of last follow-up. Three patients (12.5%) reported pain relief but had persistent vaginal bleeding requiring hysterectomy 12 months after UAE. All patients underwent a 23-hr observation postoperatively for pain control. Mean follow-up was 7.4 months (1-23 months) and included pelvic ultrasound assessment of fibroid size at 1, 3, and 6 months after UAE and annually thereafter. One patient was lost to follow-up. Fibroid shrinkage was noted in all patients. Given the willingness and capability to work-up, admit, treat, and follow-up patients, vascular surgery was deemed the preferred service for UAE by the referring gynecologists. CONCLUSION: Within the framework of a collaborative, multidisciplinary program, vascular surgery can play a prominent role in providing safe and effective UAE.

An Institution-Wide Algorithm for Treatment of Type II Endoleak Following Endovascular Aneurysm Repair (EVAR).

OBJECTIVES: Multiple endovascular techniques have been described for the treatment of persistent type II endoleaks (pT2ELs) causing aneurysm sac growth following endovascular aneurysm repair (EVAR). In the event of a failed endovascular procedure and a pT2EL, a consensus regarding further treatment is lacking, and the literature suggests repeated endovascular attempts are rarely successful. Herein, we propose an algorithm for definitive management of pT2ELs with persistent sac growth following EVAR. METHODS: A retrospective review of 29 patients who underwent treatment of persistent sac growth in the setting of pT2ELs was performed. Intervention methods were determined at the discretion of the operating surgeon. Aneurysmal sac enlargement was defined as a diameter increase > 5 mm, and persistent endoleak was defined as lasting greater than 6 months. RESULTS: From 2000 to 2015, 917 EVAR procedures were performed at our institution. Isolated pT2ELs with sac enlargement were identified in 29 patients. Twenty-five patients underwent direct translumbar sac puncture and coiling and/or Onyx (Onyx, Plymouth, Minnesota) embolization of the culprit vessels. Thirteen (52%) of 25 patients had pT2EL after first endovascular intervention, and 10 (40%) of 25 patients failed 2 endovascular treatments. Of those 10, 7 displayed persistent aneurysmal sac growth and underwent a third embolization procedure. Type II endoleaks persisted in 6 patients; 3 patients were subsequently treated with laparotomy, ligation of lumbar vessels, sac exploration, and sac plication around the endograft. Technical success for this technique was 100%. During a mean follow-up of 38.4 months, no recurrent T2ELs, stent graft migration, and/or disjunction were observed. CONCLUSIONS: We propose a new algorithm for the management of pT2ELs. If 2 endovascular procedures fail to control of the endoleak, repeat endovascular attempts are not recommended. Endovascular failure should be followed by laparotomy with surgical ligation of culprit feeding vessels followed by sac exploration and plication of the sac, and endoaneurysmorrhaphy.