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.

Transvenous Biopsies - Technique, Pearls, and Pitfalls.

Image-guided biopsies are one of the most common requests received by radiologists, and while most are straightforward, some lesions are not amenable to percutaneous sampling due to location or depth. Advances in intravascular ultrasound combined with the principles of non-targeted transvenous solid organ biopsy allow for direct visualization and successful targeted transvenous biopsies of solid organ and perivascular lesions. Here, we present our technique and three example cases of transvenous biopsies.

Management of Acute, Complicated Type B Aortic Dissection.

Management of acute complicated Type B aortic dissection (TBAD) requires a multidisciplinary approach with careful evaluation and understanding of the complicating features. Patients who present with or progress to a complicated TBAD must be triaged and managed rapidly due to the high morbidity and mortality even in the presence of optimal medical, endovascular, and open therapies. When required, invasive therapies can be broken down most simply into four treatments: thoracic endograft placement, aortic fenestration, branch vessel stenting, and open repair. However, which therapy to offer and in which order is often unclear. In this review, focus is placed on clinical presentation, diagnosis, and explanation for one or a combination of these therapies. In addition, contraindications as well as expected outcomes, complications, and adjunct therapies will be reviewed. The advent of advanced endovascular techniques has certainly improved the immediate morbidity and mortality of acute complicated TBAD; however, much remains to learn about patient selection and therapeutic intervention performed.

Predictive Value of Preprocedural Computed Tomography Angiography for the Technical Success of Transarterial Embolization of Type II Endoleaks Arising from the Lumbar Arteries.

PURPOSE: To evaluate the ability of preprocedural computed tomography angiography (CTA) to predict the technical success of embolization of type II endoleak arising from a lumbar artery after endovascular aortic repair (EVAR). MATERIALS AND METHODS: All patients at a single academic institution who underwent angiography with possible embolization for a post-EVAR lumbar-supplied type II endoleak from 2009 to 2018 were retrospectively reviewed. Patients who did not undergo CTA before the procedure were excluded. CTAs were reviewed for the ability to trace the entire course of a feeding vessel from the internal iliac artery (IIA) to the lumbar artery at the site of the endoleak. Procedural imaging was reviewed for technical success, defined as the catheterization and embolization of the aneurysm sac through a lumbar artery. RESULTS: Fifty-seven angiograms with a type II endoleak and suspected feeding lumbar artery were identified. On CTA acquired before the procedure, the arterial path supplying this lumbar artery could be traced from the IIA to the aneurysm sac in 18 (32%) patients. Embolization was technically successful in 16 of these 18 (89%) procedures compared with 10 of 39 (26%) procedures in which the supplying artery could not be traced using CTA (P < .001). CONCLUSIONS: A potential catheter path from the IIA through the iliolumbar and lumbar arteries to the aneurysm sac can be traced on preprocedural CTA in the minority of lumbar-supplied type II endoleaks. The ability to trace these inflow vessels may predict technical success during embolization. The low rate of technical success when the feeding vessel could not be traced using CTA suggests that these patients should be considered for percutaneous or transcaval sac puncture.

Thoracic Aortic Emergencies: Presenting Pathologies and Treatment Strategies.

Thoracic aortic emergencies reflect a wide range of etiologies, pathologic processes, and clinical presentations. Accurate identification with an appropriate treatment algorithm is best accomplished in a multidisciplinary setting with interventional radiologists, vascular surgeons, and cardiothoracic surgeons. While knowledge of thoracic stent graft equipment and technique is essential in the treatment of thoracic aortic emergencies, many clinical settings may employ alternative treatment techniques. This article will review the most common thoracic aortic emergencies and treatment strategies.

Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis.

PURPOSE: To evaluate safety and retrieval success of retrievable suprarenal inferior vena cava (IVC) filters. MATERIALS AND METHODS: A retrospective chart review of patients who received a retrievable suprarenal IVC filter between January 2008 and December 2017 was conducted. Suprarenal IVC filters were placed in 24 female and 27 male patients. The most common indications for filter placement were IVC thrombus (n = 20; 39.2%) and iliofemoral venous thrombosis with contraindication to anticoagulation (n = 16; 31.3%). The most common indications for suprarenal placement were IVC thrombus (n = 20; 39.2%), anatomic variants (n = 17; 33.3%), and external IVC compression (n = 8; 15.8%). Duplicated IVC was the most common anatomic variant requiring suprarenal placement (n = 7; 13.7%). RESULTS: Günther Tulip (n = 40; 78.4%), Denali (n = 10; 19.6%), and Celect (n = 1; 2.0%) filters were used. Retrieval was attempted in 27 of the 51 filters placed (52.9%). Of the 27 attempted retrievals, the technical success rate was 100% (27/27). The median dwell time was 87.0 days (95% confidence interval, 28-137 d). One complication involving fractured struts during filter retrieval occurred. No significant change in craniocaudal filter position, lateral filter tilt, or renal function between placement and retrieval was observed (P < .05). There were no instances of indwelling filter fracture. CONCLUSIONS: Suprarenal IVC filters, when indicated, can be placed and retrieved with a low complication rate.

Spontaneous Rectus Sheath Hematoma: Factors Predictive of Conservative Management Failure.

PURPOSE: To evaluate radiographic, laboratory, and clinical factors associated with conservative management (CM) failure in spontaneous rectus sheath hematoma (RSH). MATERIALS AND METHODS: Retrospective review of 72 patients with spontaneous RSH between 2006 and 2017 was performed. Patients were initially managed conservatively and then divided into 2 groups based on decision to embolize. No differences were found between embolization (n = 32) and CM (n = 40) groups in age (67.5 vs 69.5 y; P = .79), sex (31% vs 38% male; P = .58), body mass index (27.7 vs 25.7 kg/m2; P = .20), or medical comorbidities. Univariate analyses compared initial hemoglobin level, change in hemoglobin level, coagulation parameters, transfusion requirements, hematoma volume, and active extravasation on computed tomographic (CT) angiography between groups. Multivariable logistic regression identified factors predictive of CM failure. A scoring system was then created to predict CM failure. RESULTS: CM failed in 32 of 72 patients. Multivariable regression identified active extravasation on CT angiography (P = .02), hematoma volume (P = .01), and packed red blood cell (pRBC) transfusion of ≥ 4 U (P = .03) as predictors of embolization. A scoring system using these factors along with maximum rate of hemoglobin decrease yielded a sensitivity of 100% and specificity of 98% in determining need for embolization. CONCLUSIONS: CM for RSH was more likely to fail in patients with active extravasation on CT angiography, larger hematoma volume, pRBC transfusion of ≥ 4 U, and higher rate of hemoglobin decrease. Using these parameters, a scoring system was created that achieved high sensitivity and specificity in identifying patients who would require embolization.

Predictors of All-Cause Mortality after Endovascular Aneurysm Repair: Assessing the Role of Psoas Muscle Cross-Sectional Area.

PURPOSE: To evaluate psoas muscle area (PMA) as a predictor of all-cause mortality after endovascular aneurysm repair (EVAR) and compare it with other predictor variables. MATERIAL AND METHODS: Retrospective review of 407 patients who underwent EVAR over a 7-year period was performed. Demographics, comorbidity variables, and outcomes were collected. Preprocedure computed tomography scans were used to measure the PMA. Descriptive statistics summarized the demographic information and predictor variables. Kaplan-Meier analysis and univariate and multivariate Cox proportional regression analyses were performed. The main outcome measure was survival time. RESULTS: Median survival time for patients with PMA in the lowest quartile of the distribution (≤1442 mm2) was 65.5 months (95% confidence interval [95% CI] 37.7-78.9) vs 91.2 months (95% CI 77.9-110.0 when PMA >1442 mm2). Multivariate analysis revealed lower PMA was associated with decreased survival (adjusted hazard ratio [AHR] 1.68; 95% CI 1.15-2.40, P = .006). Similarly, the presence of coronary artery disease (AHR 1.54, 95% CI 1.01-2.35, P = .045) and statin use after EVAR were associated with decreased survival (AHR 2.36, 95% CI 1.24-4.49, P = .009). Hyperlipidemia was associated with increased survival after EVAR (AHR 0.51, 95% CI 0.33-0.81, P = .004). Compared with patients with low body mass index (BMI) (<18.5), a normal BMI was associated with increased survival (AHR 0.21, 95% CI 0.08-0.53, P = .001). CONCLUSIONS: Although PMA is a risk factor for decreased survival time, other factors such as patient hyperlipidemia, presence of coronary artery disease, post-EVAR statin use, and BMI are also predictive of postoperative mortality.

Impact of Venous Collaterals on Clinical Outcomes in Paget-Schroetter Syndrome.

PURPOSE: To characterize the degree of venous collateralization before and after endovascular therapy and determine the effect of collateralization on success of thrombolysis and rate of repeat intervention in patients with Paget-Schroetter syndrome. MATERIALS AND METHODS: A single-center retrospective study of 37 extremities in 36 patients (mean age, 32.64 y; range, 15-72 y; 24 men) with PSS treated with endovascular therapy from 2007 through 2017 was conducted. Venograms at presentation, after lysis, postoperatively, and at each repeat intervention were graded for venous stenosis, thrombus burden, and collateralization on a 5-point scale. Collateralization was classified as high-grade (9 extremities) or low-grade (28 extremities) based on grading of the venograms at presentation. RESULTS: Primary technical success rate for endovascular treatment was 100%. Eighty-six percent of patients (32 of 37) underwent thrombolysis, 91% (34 of 37) underwent mechanical thrombectomy, and 83% (30 of 37) underwent balloon angioplasty. Overall primary patency rate was 50% at 12 months. The repeat intervention rate within 12 months was significantly higher for extremities with high- vs low-grade collateralization (89% vs 43%; P = .016). There was a significant decrease in the median grade of collateral severity after initial intervention (2 vs 1; P = .044) and 1 day postoperatively (2 vs 1; P = .040) vs the venogram at presentation. CONCLUSIONS: Severity of venous collateralization on the venogram at presentation of patients with PSS does not appear to affect success of endovascular therapy but may predict long-term patency of affected extremities. Patients in this cohort with severe collateralization on presentation were more likely to need repeat intervention.

Long Chronic Total Occlusions: Revascularization Strategies.

The treatment of chronic total occlusions (CTO) in patients with peripheral arterial disease (PAD) is a complex topic with multiple treatment techniques and treatment strategies. The interventionalist treating patients with PAD should have both a defined treatment algorithm and multiple techniques available for crossing these challenging lesions. This article will cover techniques for treating CTOs and provide an overview of current available evidence.