Rules for Interventional Radiology.

During the hands-on teaching of Interventional Radiology (IR) to Residents and Fellows, certain learning tips or guiding statements are often repeated. Over the past two decades, these tips have evolved into the "Rules for Interventional Radiology." Relying on humour and the technical and foundational principles of our subspeciality, it is hoped that these Rules for IR provide helpful guidance to learners and practising Interventionalists in their daily work.

Uterine Artery Embolization for Pedunculated Subserosal Fibroids: A Systematic Review and Meta-Analysis.

PURPOSE: To provide a comprehensive overview of the literature assessing the safety and efficacy of uterine artery embolization (UAE) for patients with pedunculated subserosal fibroids. MATERIALS AND METHODS: MEDLINE and Embase databases were searched without language or publication type restrictions for observational studies to estimate safety (adverse events) and efficacy (devascularization, fibroid volume reduction, and uterine volume reduction) outcomes. Case reports were included to qualitatively report adverse events. Meta-analysis was performed for single proportions and mean changes with random-effects modeling. RESULTS: Of 98 eligible articles, 11 studies were included in the final analysis. Of the adverse events detailed in these cases, 5 events were mild, 2 were moderate (torsion of pedunculated fibroid requiring laparoscopic myomectomy and persistent bleeding after embolization requiring hysterectomy), and 1 was severe (fibroid necrosis causing bowel obstruction requiring bowel resection and hysterectomy). There were no deaths reported in the literature. The pooled risk of adverse events was 1.7% (95% confidence interval [CI], 0.29%-9.2%; 4 of 181; I2 = 0%). The pooled devascularization rate was 75.9% (95% CI, 62.4%-85.6%; 140 of 189; I2 = 75%) at 3.91 months of follow-up. The percent volume reduction of the dominant pedunculated fibroid was 38.6% (95% CI, 33.0%-44.2%; I2 = 0%) at 4.3 months of follow-up. The percent uterine volume reduction was 36.7% (95% CI, 30.3%-43.0%; I2 = 47%) at 3.5 months of follow-up. CONCLUSIONS: UAE for pedunculated subserosal fibroids has a low risk of adverse events and effectively reduces fibroid and uterine size.

Safety of High-Dose 3% Sodium Tetradecyl Sulfate for Sclerotherapy of Renal Cysts in Patients with Autosomal Dominant Polycystic Kidney Disease.

This study assessed the safety profile of high-volume (>10 mL) 3% sodium tetradecyl sulfate (STS) sclerotherapy for the treatment of renal cysts in patients with autosomal dominant polycystic kidney disease. A total of 211 sclerotherapy treatments were performed in 169 patients over a 5-year period, with a comparison of 2 patient cohorts based on the STS volumes used. The first cohort (n = 112) received a high volume (greater than 10 mL) of STS, and the second cohort (n = 57) received a low volume (less than 10 mL). The minor adverse event rate for the cohorts was 14.5% and 9.6%, respectively (P = .310), with postprocedure pain being the most common event. One major adverse event occurred, for which the patient required hospitalization for infection after low-volume STS treatment. Doses of STS higher than those currently recommended by the Food and Drug Administration for intravascular use allow large renal cysts to be treated safely in the setting of autosomal dominant polycystic kidney disease.

Selective fetal reduction in complicated monochorionic twin pregnancies: A comparison of techniques.

OBJECTIVE: To compare perinatal outcomes associated with three methods of selective reduction in complicated monochorionic (MC) twin pregnancies: bipolar cord coagulation (BC), fetoscopic or ultrasound guided laser cord occlusion and radiofrequency ablation (RFA). METHODS: Retrospective cohort study of complicated MC twin pregnancies undergoing selective fetal reduction at a tertiary fetal center over a 20-year period. Obstetric and perinatal outcomes were compared. RESULTS: 105 procedures met inclusion criteria: 74 RFAs, 17 lasers and 14 BCs. Procedure duration was significantly shorter for RFA (27.4 ± 15.8 minutes) compared to BC (91.7 ± 38.7 minutes) and laser (83.4 ± 40.4 minutes), P < .0001). The incidence of preterm prelabor rupture of membranes (PPROM) and co-twin demise did not differ between groups, however preterm delivery <34 weeks occurred less frequently following RFA (29.7%), compared to laser (64.7%) or BC (42.9%) (P = .02); delivery <37 weeks was also less frequent following RFA (45.9%), compared to laser (76.5%) or BC (78.6%)(P = .01). The difference in preterm birth<34 weeks between RFA and laser was maintained after adjusting for cord occlusion indication and amnionicity (OR 3.96, 95% CI 1.27-12.31). CONCLUSIONS: In our experience, RFA procedures were simpler, faster and associated with a lower risk of preterm delivery <34 and <37 weeks, compared to laser or BC.

Overall Impact of the COVID-19 Pandemic on Interventional Radiology Services: A Canadian Perspective.

PURPOSE: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada. METHODS: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics. RESULTS: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%). CONCLUSION: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

Outcomes of radiofrequency ablation as first-line therapy for hepatocellular carcinoma less than 3 cm in potentially transplantable patients.

BACKGROUND & AIMS: Radiofrequency ablation (RFA) is an effective treatment for single hepatocellular carcinoma (HCC) ≤3 cm. Disease recurrence is common, and in some patients will occur outside transplant criteria. We aimed to assess the incidence and risk factors for recurrence beyond Milan criteria in potentially transplantable patients treated with RFA as first-line therapy. METHODS: We performed a retrospective cohort study of potentially transplantable patients with new diagnoses of unifocal HCC ≤3 cm that underwent RFA as first-line therapy between 2000-2015. We defined potentially transplantable patients as those aged <70 years without any comorbidities that would preclude transplant surgery. Incidence of recurrence beyond Milan criteria was compared across 2 groups according to HCC diameter at the time of ablation: (HCC ≤2 cm vs. HCC >2 cm). Competing risks Cox regression was used to identify predictors of recurrence beyond Milan criteria. RESULTS: We included 301 patients (167 HCC ≤2 cm and 134 HCC >2 cm). Recurrence beyond Milan criteria occurred in 36 (21.6%) and 47 (35.1%) patients in the HCC ≤2 cm and the HCC >2 cm groups, respectively (p = 0.01). The 1-, 3- and 5-year actuarial survival rates after RFA were 98.2%, 86.2% and 79.0% in the HCC ≤2 cm group vs. 93.3%, 77.6% and 70.9% in the HCC >2 cm group (p = 0.01). Tumor size >2 cm (hazard ratio 1.94; 95%CI 1.25-3.02) and alpha-fetoprotein levels at the time of ablation (100-1,000 ng/ml: hazard ratio 2.05; 95%CI 1.10-3.83) were found to be predictors of post-RFA recurrence outside Milan criteria. CONCLUSION: RFA for single HCC ≤3 cm provides excellent short- to medium-term survival. However, we identified patients at higher risk of recurrence beyond Milan criteria. For these patients, liver transplantation should be considered immediately after the first HCC recurrence following RFA. LAY SUMMARY: Radiofrequency ablation and liver transplantation are treatment options for early stages of hepatocellular carcinoma (HCC). After ablation some patients will experience recurrence or metastatic spread of the initial tumor or may develop new tumors within the liver. Despite close follow-up, these recurrences can progress rapidly and exceed transplant criteria, preventing the patient from receiving a transplant. We identified that patients with HCC >2 cm and higher serum alpha-fetoprotein are at greater risk of recurrence beyond the transplant criteria. These data suggest that liver transplantation should be considered immediately after the first HCC recurrence for these patients.

Liver Transplantation is Equally Effective as a Salvage Therapy for Patients with Hepatocellular Carcinoma Recurrence Following Radiofrequency Ablation or Liver Resection with Curative Intent.

BACKGROUND: Liver resection (LR) and radiofrequency ablation (RFA) are curative-intent therapies for early stages of hepatocellular carcinoma (HCC). If HCC recurs, salvage liver transplant (SLT) may constitute a treatment option. OBJECTIVE: We aimed to compare the outcomes of patients transplanted for recurrent HCC after curative-intent therapies with those transplanted as initial therapy. METHODS: We conducted a matched-control (1:1) cohort study comparing patients with HCC treated with primary liver transplant (PLT) with SLT after HCC recurrence. Matching was performed according to the size and number of viable tumors at explant pathology following liver transplant. RESULTS: Between November 1999 and December 2014, 687 patients with HCC were listed for transplant at our institution. A total of 559 patients were transplanted; 509 patients were treated with PLT and 50 patients were treated with SLT for HCC recurrence after primary treatment with LR (n = 25) or RFA (n = 25). The median length of follow-up from transplant was 64 months (0.5-195), and the median time from curative-intent treatment of HCC with RFA or LR to recurrence was 9.5 months (1-36) and 14.5 months (3-143), respectively (p = 0.04). The matched cohort was composed of 48 SLT patients (23 LR and 25 RFA) and 48 PLT patients. The 5-year risk of recurrence after LT was 22% in the PLT group versus 32% in the SLT group (p = 0.53), while the 5-year actuarial patient survival after PLT was 69% versus 70% in the SLT group (p = 1). CONCLUSION: Liver transplant is an effective treatment for patients with HCC recurrence following RFA or LR. Outcomes are similar in both groups.

Clinical IR in Canada: The Evolution of a Revolution.

PURPOSE: To investigate the current status and evolution of both the interventional radiologist's role as a clinician and the practice of interventional radiology (IR) over the past decade in Canada. MATERIALS AND METHODS: In 2015, an online survey was e-mailed to 210 interventional radiologists, including all Canadian active members of the Canadian Interventional Radiology Association (CIRA) and nonmembers who attended CIRA's annual meeting. Comparisons were made between interventional radiologists in academic versus community practice. The results of the 2015 survey were compared with CIRA's national surveys from 2005 and 2010. RESULTS: A total of 102 interventional radiologists responded (response rate 49%). Significantly more academic versus community interventional radiologists performed chemoembolization, transjugular intrahepatic portosystemic shunt, aortic interventions, and arteriovenous malformation embolization (P < .05). Ninety percent of respondents were involved in longitudinal patient care, which had increased by 42% compared with 2005; 46% of interventional radiologists had overnight admitting privileges, compared with 39% in 2010 and 29% in 2005. Eighty-six percent of interventional radiologists accepted direct referrals from family physicians, and 83% directly referred patients to other consultants. Sixty-three percent participated in multidisciplinary tumor board. The main challenges facing interventional radiologists included a lack of infrastructure, inadequate remuneration for IR procedures, and inadequate funding for IR equipment. Significantly more community versus academic interventional radiologists perceived work volume as an important issue facing the specialty in 2015 (60% vs 34%; P = .02). CONCLUSIONS: Over the past decade, many Canadian interventional radiologists have embraced the interventional radiologist-clinician role. However, a lack of infrastructure and funding continue to impede more widespread adoption of clinical IR practice.

Radiofrequency Ablation of T1a Renal Cell Carcinomas within Renal Transplant Allografts: Oncologic Outcomes and Graft Viability.

PURPOSE: To evaluate oncologic outcomes and graft viability after percutaneous radiofrequency (RF) ablation of renal cell carcinoma (RCC) developing within renal transplant allografts. MATERIALS AND METHODS: A single-institution, retrospective study reviewed all patients treated with RF ablation for RCC between February 2004 and May 2016. Ten patients were identified (age 49.6 y ± 12.6; 9 men, 1 woman) with 12 biopsy-confirmed RCC tumors within the allograft (all T1a, mean diameter 2.0 cm ± 0.7). Mean time from transplant to RCC diagnosis was 13.2 years ± 6.3. RF ablation was performed on an outpatient basis using conscious sedation. Procedural efficacy, complications, oncologic outcomes, and allograft function were evaluated. Statistical analysis with t tests and Pearson correlation compared allograft function before and after RF ablation and impact of proportional ablation size to allograft volume on function after ablation. RESULTS: Technical success rate and primary technique efficacy were 100% (12/12). No local or distant RCC progression was seen at mean follow-up of 54.3 months ± 38.7 (range, 9-136 months). Graft failure requiring hemodialysis or repeat transplantation occurred in 3 patients (26, 354, and 750 d after RF ablation), all of whom had glomerular filtration rate (GFR) < 30 mL/min/1.73 m2 before ablation. For all patients, mean GFR 6 months after RF ablation (35.8 mL/min/1.73 m2 ± 17.7) was not significantly different (P = .8) from preprocedure GFR (36.2 mL/min/1.73 m2 ± 14.3). Proportional volume of allograft that was ablated did not correlate with immediate or long-term GFR changes. One patient died of unrelated comorbidities 52 months after ablation. No major complications occurred. CONCLUSIONS: RF ablation of renal allograft RCC provided effective oncologic control without adverse impact on graft viability.

Thermal Ablation versus Surgical Resection for the Treatment of Stage T1 Hepatocellular Carcinoma in the Surveillance, Epidemiology, and End Results Database Population.

PURPOSE: To compare survival outcomes of small solitary hepatocellular carcinomas (HCCs) treated with thermal ablation vs resection in the Surveillance, Epidemiology, and End Results (SEER) cohort. MATERIALS AND METHODS: SEER data (November 2014 submission) were searched for histologic diagnoses of HCC and stage T1 disease (≤ 5-cm solitary tumor without vascular invasion). Comparison was made between thermal ablation and resection as the primary treatment. Overall and disease-specific survival were compared by log-rank tests (stratified for presence of fibrosis) and Cox regression (with tumor size and presence of fibrosis covariates). RESULTS: Of 264 patients with ≤ 2-cm HCCs, 185 underwent thermal ablation and 79 underwent resection. Patients undergoing ablation had higher Ishak scores (P = .0002). There was no difference in survival (observed P = .698, disease-specific P = .446). Of 544 patients with 2.1-4-cm HCCs, 335 underwent thermal ablation and 209 underwent resection. Patients undergoing ablation were more likely to have higher Ishak scores (P < .001), but had slightly smaller tumors (2.9 vs 3.1 cm; P < .001). There was no difference in survival (observed P = .174, disease-specific P = .609). Of 112 patients with 4.1-5-cm HCCs, 46 underwent thermal ablation and 66 underwent resection. Patients undergoing ablation had higher Ishak scores (P = .0002). Surgical resection was associated with improved survival (observed P = .009, disease-specific P = .046). CONCLUSIONS: There was no difference in overall or disease-specific survival between surgical resection and thermal ablation for T1 HCCs ≤ 4 cm after adjusting for the presence of histologic fibrosis and tumor size in the SEER cohort. Significant benefit was observed with surgery for tumors measuring 4.1-5 cm.

Comparison of Clinical Outcomes following Glue versus Polyvinyl Alcohol Portal Vein Embolization for Hypertrophy of the Future Liver Remnant prior to Right Hepatectomy.

PURPOSE: To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group). MATERIALS AND METHODS: Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ2 tests. RESULTS: Technical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE. CONCLUSIONS: PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.

Obstetric and Anaesthesia Checklists for the Management of Morbidly Adherent Placenta.

OBJECTIVE: To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). METHODS: A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. RESULTS: Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. CONCLUSIONS: Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

Randomized Trial Comparing Radiologic Pigtail Gastrostomy and Peroral Image-Guided Gastrostomy: Intra- and Postprocedural Pain, Radiation Exposure, Complications, and Quality of Life.

PURPOSE: To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured. MATERIALS AND METHODS: Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined. RESULTS: Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 µg, respectively, for PG vs 1.9 mg and 105 µg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation. CONCLUSIONS: Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization.

PURPOSE: The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery. METHODS: Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity. RESULTS: All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%. CONCLUSION: Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

Efficacy of Ovarian Artery Embolization for Uterine Fibroids: Clinical and Magnetic Resonance Imaging Evaluations.

PURPOSE: The objective of the study was to assess the efficacy of ovarian artery embolization (OAE) treatment for symptomatic uterine leiomyomas. METHODS: A retrospective review of 17 patients who underwent OAE in conjunction with uterine artery embolization in a 6-year period (2006-2012) was performed. Ten patients had previous failed embolization, while 7 had not received any embolization therapy before. Percent uterine volume change, percent dominant fibroid volume change, and percent dominant fibroid infarction were assessed with magnetic resonance (MR) imaging. Resolution of menorrhagia, dysmenorrhea/pain, and bulk and/or pressure symptoms including urinary frequency were evaluated clinically. Change in menopausal state was also an outcome of interest. RESULTS: Mean MR imaging follow-up was performed 3 months post-OAE. MR images showed complete infarction in the majority of cases (64.7%; n = 11), with infarction rates of 90%-100% in 3 cases, 1 case with 30%-50% infarction, and 2 cases with 0%-10% infarction. Average uterine size reduction on MR was 32.3% (95% confidence interval [CI]: 22.5%-42.2%; P < .001). The average size reduction for the dominant fibroid was 42.4% (95% CI: 27.7%-57.0%; P = .01). The mean time to final follow-up visit was 11 months. At this point complete symptom resolution (menorrhagia, dysmenorrhea and bulk-related) was achieved in 82.4% (n = 14) of cases. At the final follow-up 11.8% (n = 2) of cases reported menopause. CONCLUSIONS: We observed OAE to be an effective and safe adjunct to uterine artery embolization when hypertrophic ovarian artery(ies) require intervention. However, incomplete fibroid infarction of 23% remains a concern with a potential for long-term treatment failure. In addition, long-term effect on ovarian function is uncertain.

Laparoscopic myomectomy versus uterine artery embolization: long-term impact on markers of ovarian reserve.

OBJECTIVE: To compare the relative long-term effects on ovarian reserve of treating fibroids in reproductive-aged women with uterine artery embolization (UAE) versus laparoscopic myomectomy (LM), using sensitive measures including antral follicle count (AFC) and serum anti-Müllerian hormone (AMH). METHODS: We undertook a retrospective cohort pilot study to evaluate the utility and feasibility of carrying out a larger prospective trial. Thirteen women were evaluated in this study, including eight in the UAE group and five in the LM group. They were identified from a larger group of 125 women who had undergone LM and 200 women who had undergone UAE at a participating institution at least 12 months previously; of these, 32 who had UAE and 27 who had LM were of reproductive age and eligible to participate. Participants had an assessment of ovarian reserve including measurements of serum AMH, estradiol, and FSH, and ultrasound assessment of AFC and ovarian volume. RESULTS: Median serum AMH levels were significantly lower in women who had undergone UAE at least 12 months previously than in women who had undergone LM (0.78 ng/mL [range 0.67 to 1.28] vs. 2.17 ng/mL [range 1.17 to 2.38], P = 0.01). Median AFC per ovary was also significantly lower in women who had UAE than in those who had LM (3.5 [range 2 to 7] vs. 7 [range 6 to 11], P = 0.03). Median levels of FSH and E2 and of ovarian volume were not significantly different between the two groups. CONCLUSION: Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term (> 12 months) than women with fibroids treated with LM. This could have an adverse impact on future response to fertility treatment and/or fecundity. This finding may inform the choice of minimally invasive treatment for fibroids in reproductive-aged women who have not completed childbearing. It suggests that further study in this area is warranted before the application of UAE is expanded to young reproductive-aged women.

Objectif : Comparer, chez des femmes en âge de procréer, la prise en charge de fibromes par embolisation de l'artère utérine (EAU) à leur prise en charge au moyen d'une myomectomie par laparoscopie (ML), pour ce qui est des effets relatifs à long terme sur la réserve ovarienne (déterminés au moyen de mesures sensibles, dont la numération des follicules antraux [NFA] et le taux sérique d'hormone antimüllérienne [HAM]). Méthodes : Nous avons mené une étude de cohorte rétrospective pilote afin d'évaluer l'utilité et la faisabilité de mener un essai prospectif de plus grande envergure. Treize femmes ont été évaluées dans le cadre de cette étude (huit dans le groupe EAU et cinq dans le groupe ML). Elles ont été identifiées à partir d'un groupe plus étendu comprenant 125 femmes qui avaient subi une ML et 200 femmes qui avaient subi une EAU au sein d'un établissement participant au moins 12 mois au préalable; de ces femmes, 32 de celles qui avaient subi une EAU et 27 de celles qui avaient subi une ML étaient en âge de procréer et admissibles à l'étude. Les participantes ont été soumises à une évaluation de leur réserve ovarienne (mesures des taux sériques d'HAM, d'estradiol et de FSH, et évaluation échographique de la NFA et du volume ovarien). Résultats : Les taux sériques médians d'HAM étaient considérablement moins élevés chez les femmes qui avaient subi une EAU au moins 12 mois au préalable que chez les femmes qui avaient subi une ML (0,78 ng/ml [plage : 0,67 - 1,28] vs 2,17 ng/ml [plage : 1,17 - 2,38], P = 0,01). La NFA médiane par ovaire était également considérablement moins élevée chez les femmes qui avaient subi une EAU que chez celles qui avaient subi une ML (3,5 [plage : 2 - 7] vs 7 [plage : 6 - 11], P = 0,03). Le volume ovarien et les taux médians de FSH et d'E2 n'étaient pas considérablement différents d'un groupe à l'autre. Conclusion : Les femmes en âge de procréer qui ont fait l'objet d'une EAU visant la prise en charge de leurs fibromes pourraient présenter, à long terme (> 12 mois), une réserve ovarienne moins élevée que celle des femmes ayant vu leurs fibromes être pris en charge au moyen d'une ML, ce qui pourrait exercer un effet indésirable sur la fertilité et/ou sur la réaction à de futurs traitements de procréation assistée. Cette constatation pourrait éclairer la décision quant au recours à un traitement à effraction minimale pour assurer la prise en charge des fibromes chez les femmes en âge de procréer qui souhaitent encore connaître une ou des grossesses. Elle laisse également entendre que la tenue d'autres études dans ce domaine s'avère justifiée avant que le recours à l'EAU ne soit élargi aux jeunes femmes en âge de procréer.

Multidisciplinary management of invasive placenta previa.

OBJECTIVE: To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa. METHODS: We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism). RESULTS: All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R2 = 0.228, P = 0.005). CONCLUSION: Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.

Objectif : Évaluer l'efficacité d'une approche d'équipe multidisciplinaire visant l'atténuation de la morbidité maternelle grave chez les femmes qui présentent un placenta prævia invasif. Méthodes : Nous avons mené une étude prospective auprès de 33 femmes qui présentaient un placenta prævia et increta-percreta (diagnostiqué par échographie et/ou imagerie par résonance magnétique) et qui accouchaient au Mount Sinai Hospital de Toronto, à la suite du lancement (en janvier 2008) d'une approche d'équipe visant les femmes qui présentaient une telle placentation. Nous avons inclus les accouchements chez les femmes visées jusqu'en juin 2012. Nous avons analysé les dossiers prénataux (services externes et services hospitaliers) en vue d'y repérer l'utilisation par l'obstétricien titulaire de six composantes d'équipe prédéfinies : (1) consultation prénatale en médecine fœto-maternelle; (2) consultation en chirurgie gynécologique; (3) IRM prénatale; (4) consultation en radiologie interventionnelle et mise en place préopératoire de sondes à ballonnet dans les divisions antérieures des artères iliaques internes; (5) planification à l'avance de la date de chirurgie; et (6) chirurgie menée par des membres de l'équipe chirurgicale vouée aux cas de placenta invasif. Les détails de l'évolution prénatale, de l'accouchement et de la période postpartum ont été consignés afin d'établir un score composite de morbidité maternelle grave en cinq points fondé sur la présence ou l'absence de ce qui suit : (1) admission à l'USI à la suite de l'accouchement; (2) transfusion de plus de deux unités de sang; (3) anesthésie générale (administration ou conversion); (4) temps opératoire se situant dans le quartile le plus élevé (> 125 minutes); et (5) complications postopératoires significatives (réhospitalisation, hospitalisation postpartum prolongée et/ou embolie pulmonaire). Résultats : Les 33 participantes ont survécu au cours de cette période. Les deux tiers (22/33) d'entre elles présentaient cinq ou six des six composantes des soins multidisciplinaires. L'utilisation croissante des composantes des soins multidisciplinaires a été associée à une baisse significative de la morbidité composite (R2 = 0,228, P = 0,005). Conclusion : L'évaluation et la prise en charge en équipe des femmes qui présentent un placenta prævia invasif sont susceptibles d'améliorer les issues maternelles et devraient être favorisées sur une base régionale.

Radiofrequency coil for the creation of large ablations: ex vivo and in vivo testing.

PURPOSE: Various radiofrequency (RF) ablation electrode designs have been developed to increase ablation volume. Multiple heating cycles and electrode positions are often required, thereby increasing treatment time. The objective of this study was to evaluate the performance of a high-frequency monopolar induction coil designed to produce large thermal lesions (>3 cm) with a single electrode insertion in a treatment time of less than 10 minutes. MATERIALS AND METHODS: A monopolar nitinol interstitial coil operated at 27.12 MHz and 200 W was evaluated. Ex vivo performance was tested in excised bovine liver (n = 22). In vivo testing (n = 10) was conducted in livers of seven Yorkshire pigs. Visual inspection, contrast-enhanced computed tomography (CT), and pathologic evaluation of ablation zones were performed. RESULTS: Average ablation volumes in ex vivo and in vivo tests were 60.5 cm(3) ± 14.1 (5.9 × 4.4 × 4.4 cm) and 57.1cm(3) ± 13.8 (6.1 × 4.5 × 4.1cm), with average treatment times of 9.0 minutes ± 3.0 and 8.4 minutes ± 2.7, respectively. Contrast-enhanced CT ablation volume measurements corresponded with findings of gross inspection. Pathologic analysis showed morphologic and enzymatic changes suggestive of tissue death within the ablation zones. CONCLUSIONS: The RF ablation coil device successfully produced large, uniform ablation volumes in ex vivo and in vivo settings in treatment times of less than 10 minutes. Ex vivo and in vivo lesion sizes were not significantly different (P = .53), suggesting that the heating efficiency of this higher-frequency coil device may help to minimize the heat-sink effect of perfusion.

Planned caesarean hysterectomy versus "conserving" caesarean section in patients with placenta accreta.

OBJECTIVES: Invasive placentation (placenta accreta, increta, or percreta) presents significant challenges at Caesarean section. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed two divergent surgical approaches: planned Caesarean hysterectomy versus a "conserving surgery" in which the placenta is left in situ after Caesarean section. METHODS: We conducted a single-centre retrospective review of all patients who delivered with invasive placentation between 2000 and 2009. We included only patients with antenatally diagnosed invasive placentation and planned mode of delivery. RESULTS: Twenty-six patients met the inclusion criteria. Caesarean hysterectomy was planned in 16 patients and conserving surgery in 10. Intraoperative and postoperative complications were comparable in the two groups. Four of 10 patients initially treated by conservative surgery required a subsequent hysterectomy for severe vaginal bleeding, coagulopathy, or sepsis. No pregnancies were subsequently reported in the conserving surgery group. CONCLUSION: An initial conserving surgical procedure is an option in patients with extensive invasive placentation, but it requires further monitoring for potential complications and carries a high subsequent hysterectomy rate.

Radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation.

BACKGROUND: Radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) is widely utilized as a bridge to liver transplant with limited evidence to support efficacy. The purpose of the present study was to measure the effect of RFA on time to drop-off in HCC-listed patients. METHODS: Patients with Milan criteria tumours listed between January 1999 and June 2007 were stratified into RFA (n= 77) and No Treatment groups (n= 93). RESULTS: The primary effectiveness of RFA was 83% (complete radiographic response). RFA was associated with a longer median wait time to transplant (9.5 vs. 5 months). Tumour-specific drop-off events were equivalent between RFA (21%) and No Treatment (12%) groups (P= 0.11). Controlling for wait time, there was no difference in overall (P= 0.56) or tumour-specific drop-off (P= 0.94). Furthermore, there were no differences in 5-year overall or tumour-free survivals from list date or transplant. Using multivariate analysis, the likelihood of receiving a transplant and patient survivals were associated with tumour characteristics (AFP, tumour number and size) and not with bridge therapy or waiting time. DISCUSSION: RFA allows patients to be maintained longer on the waiting list without negative consequences on drop-off or survival compared with no treatment. Post-transplant outcomes are affected more by tumour characteristics than RFA or wait time.