Clinical utility of ultrasound versus magnetic resonance imaging for deciding to proceed with uterine artery embolization for presumed symptomatic fibroids.

AIM: To compare the diagnostic utility of pelvic ultrasound (US) and magnetic resonance imaging (MRI) on the clinical decision to proceed with uterine artery embolization (UAE). MATERIALS AND METHODS: Over 2 years, 180 consecutive women (mean age 43) sought consultation for UAE, 116 underwent pelvic US and MRI before possible UAE. US was performed prior to MRI. Imaging was analysed for leiomyoma quantity, size and location, uterine volume, and the presence of potential contraindications to UAE. Discrepancies between imaging methods and cases where discrepancies could have altered management, were recorded. RESULTS: For the 116 patients who completed imaging, the average uterine volume was 701 cm(3) using MRI versus 658 cm(3) using US (p=0.48). The average dominant leiomyoma volume was 292 cm(3) using MRI versus 253 cm(3) using US (p=0.16). In 14 (12.1%) patients US did not correctly quantify or localize leiomyomas compared with MRI (p=0.0005). Thirteen patients did not undergo UAE (patient preference n=9, pre-procedural imaging findings n=4). In the four cases where UAE was not performed due to imaging findings, relevant findings were all diagnosed by MRI compared with two by US (p=0.5). The two cases not detected by ultrasound were adenomyosis and a pedunculate subserosal leiomyoma. Of the 103 patients who underwent UAE, 14 were treated (without complication) despite the presence of a relative contraindication; all 14 relative contraindications were identified by MRI compared with 13 by US (p=1.0). CONCLUSION: MRI is more accurate than US for characterizing uterine leiomyomas. In a small but statistically insignificant number of cases, MRI identified findings that were missed by US, which changed management. For patients that are unsuitable to be assessed with MRI, ultrasound alone is sufficient for pre-UAE assessment.

Percutaneous transluminal dilation in renal transplant arterial stenosis.

Twelve hypertensive patients underwent percutaneous transluminal dilation (PTD) for relief of arterial stenosis complicating renal allotransplantation. Two patients underwent repeat PTD for recurrent stenosis and hypertension. Six patients had end to end anastomosis of the donor renal artery to the recipient hypogastric artery; four of six PTDs were successful. Six patients had end to side anastomosis of the donor renal artery to the recipient external iliac artery; seven of eight PTDs, including one of two repeat PTDs, were successful. Prior to PTD, all patients were using several antihypertensive medications. Following successful PTD, the mean blood pressure dropped from 184 +/- 15/118 +/- 9 to 133 +/- 13/89 +/- 11 mm Hg (P < 0.001) and remained at that level for up to 15 months (average followup 9 months) with decreased or no antihypertensive medications. Since surgical correction of arterial stenosis occurring after renal transplantation is difficult and may endanger the graft, PTD should be the first interventional therapy.

Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Y-microspheres.

UNLABELLED: Treatment for nonresectable hepatocellular carcinoma (HCC) is palliative. The relatively greater arteriolar density of hepatic tumors compared with normal liver suggests that intrahepatic arterial administration of 90Y-microspheres can be selectively deposited in tumor nodules and results in significantly greater radiation exposure to the tumor than external irradiation. The purpose of this study was to determine the proportion (frequency) and duration of response, survival, and toxicity after intrahepatic arterial injection of 90Y-microspheres in patients with HCC. METHODS: Patients with documented HCC, Eastern Cooperative Oncology Group performance status 0-3, adequate bone marrow, and hepatic and pulmonary function were eligible for study. Patients who had significant shunting of blood to the lungs or gastrointestinal (GI) tract or who could not undergo cannulation of the hepatic artery were excluded. Patients received a planned dose of 100 Gy through a catheter placed into the hepatic artery. RESULTS: Twenty-two patients were treated with 90Y-microspheres; 20 of the treated patients (median age, 62.5 y) were evaluated for treatment efficacy. Nine patients were Okuda stage I, and 11 were Okuda stage II. The median dose delivered was 104 Gy (range, 46-145 Gy). All 22 treated patients experienced at least 1 adverse event. Of the 31 (15%) serious adverse events, the most common were elevations in liver enzymes and bilirubin and upper GI ulceration. The response rate was 20%. The median duration of response was 127 wk; the median survival was 54 wk. Multivariable analysis suggested that a dose >104 Gy (P = 0.06), tumor-to-liver activity uptake ratio >2 (P = 0.06), and Okuda stage I (P = 0.07) were associated with longer survival. CONCLUSION: Significantly higher doses of radiation can be delivered to a HCC tumor by intrahepatic arterial administration of 90Y-microspheres than by external beam radiation. This treatment appears to be beneficial in nonresectable HCC with acceptable toxicity.

Transcatheter embolization with Gelfoam and Avitene: the effect of Sotradecol on the duration of arterial occlusion.

Selective catheterization and embolization of both profunda femoris arteries were performed on eight mongrel dogs. In four dogs, Gelfoam alone (one side), and Gelfoam soaked in Sotradecol (contralateral side) was the embolic agent. In the other four dogs, Avitene in saline (one side), and Avitene suspended in Sotradecol (contralateral side) was the embolic agent. Ateriography followed by sacrifice and histologic examination were performed at two weeks (two dogs in each group) and two months (two dogs in each group) following embolization. In all dogs, histology confirmed the arteriographic appearance. In Gelfoam-embolized dogs, arteries embolized with Gelfoam alone were recanalized by two weeks; arteries embolized with Gelfoam/Sotradecol remained occluded at two months. In Avitene-embolized dogs, arteries embolized with Avitene in saline were moderately recanalized by two weeks and totally recanalized by two months; arteries embolized with Avitene/Sotradecol remained occluded at two months. Inflammatory changes were present in the walls of arteries embolized with Sotradecol. Sotradecol greatly increases the duration of arterial occlusion in Gelfoam and Avitene-embolized arteries.

Biliary pressure measurement: an aid in the management of patients on internal biliary drainage.

To aid in the management of patients with internal biliary drainage catheters, biliary pressure readings are routinely taken. If the pressure is below the secretory pressure of bile (20-30 cm H2O), adequate internal biliary drainage is assured. This is a fast, simple, and reliable technique which can be performed at home by the patient or a visiting nurse. The need to exchange a catheter can now be based on the objective measurement of the biliary pressure.

Pulmonary arteriography for the assessment of technical feasibility of sleeve resection in lung cancer.

BACKGROUND: Pulmonary arteriography has been reported to be useful in the preoperative assessment of patients with lung cancer to determine the technical resectability and feasibility of pneumonectomy by imaging the main right and left pulmonary arteries. In this report, we describe the use of selective pulmonary arteriography in the assessment of lobar resectability. METHODS: Selective pulmonary arteriography provides a detailed anatomic view of the lobar branches and has been used at our institution for the past 30 years to preoperatively investigate patients who are candidates for a sleeve lobectomy. RESULTS: Three cases are described that demonstrate the usefulness of selective pulmonary arteriography in the assessment of the technical feasibility of sleeve resection in patients with lung cancer. CONCLUSIONS: Arteriographic findings may accurately show whether a sleeve lobectomy is technically possible, that only a pneumonectomy is possible, or that the only safe way to ensure clearance of the pulmonary artery is to perform arterioplasty. This information may obviate an unnecessary thoracotomy in patients who are judged on the basis of a physiologic assessment to be unable to tolerate a pneumonectomy.

Management of total parenteral nutrition-related superior vena cava obstruction with expandable metal stents.

Catheter-related thrombotic and stenotic obstructions are the second most common serious complication of long-term total parenteral nutrition. Subsequent venous access problems have profound implications because of immediate and long-term requirements of nutrition support. Although improved understanding of pathogenesis has led to improved prophylaxis and treatment of thrombosis, some patients will have refractory obstructions that threaten venous access and lead to severe clinical sequelae, including superior vena cava (SVC) syndrome. We describe two cases of patients with SVC syndrome refractory to anticoagulant, thrombolytic, and balloon angioplasty therapy, managed successfully with percutaneous placement of expandable metal stents. A discussion of the current understanding of prophylaxis and treatment of catheter-related thrombosis and the role for interventional measures to restore venous patency and avoid permanent venous access problems accompanies the case descriptions.

Case report: avascular necrosis of the femoral head as a complication of complex embolization for severe pelvic haemorrhage.

We present a case of avascular necrosis of the femoral head following embolization of the right medial femoral circumflex artery with alcohol after a failed prior internal iliac artery ligation to control benign pelvic haemorrhage in a 41-year-old woman. No case of late necrosis of the head of the femur as a complication of iliac artery vessel embolization to control haemorrhage has been documented previously. The problems associated with therapeutic pelvic embolization following ligation of the internal iliac artery and the disruption of the femoral head arterial supply are discussed.

Hepatic venography in the surgical assessment of hepatic tumours.

Hepatic venography was performed on 80 patients with hepatic tumours for the pre-operative assessment of resectability. Sixty-six patients subsequently underwent laparotomy, 27 undergoing hepatic resection. Forty-two patients had metastases from colo-rectal primaries, 19 hepatocellular carcinoma and 19 a variety of other tumours. The type and frequency of the abnormalities shown on venography were noted for each tumour category and for their hepatic segmental distribution. The results of venography were compared with those of arteriography, computed tomography and ultrasound and with the findings at laparotomy. Displacement was the commonest abnormality seen while encasement or obstruction occurred less frequently and tumour invasion was rare. The sensitivity of venography in correctly identifying the segmental distribution of tumour deposits was 41%. Sensitivity was poorest with tumours in the left lobe (31%) and bilobar tumours (0%). Venography was most sensitive in detecting tumour involvement of the major segmental hepatic veins and inferior vena cava (100%). Peripheral colo-rectal metastases frequently produced no venographic abnormality. Hepatic venography provides no additional information to arteriography, computed tomography or ultrasound in patients with peripheral or bilobar tumour deposits. Some additional information may be obtained with central tumours and venography is the most accurate means of detecting tumour involvement of the major segmental hepatic veins.

Percutaneous aspiration embolectomy.

Percutaneous aspiration thromboembolectomy (PAT) for management of a spontaneous arterial embolus, or following a complication of balloon angioplasty, was initially described in 1984. Instrument developments using a new clot aspiration system have facilitated this procedure. We report a case where PAT was successful in retrieving a spontaneous arterial embolus, and describe this new technique. We feel that PAT broadens the armamentarium of the vascular surgeon in the management of emboli to the distal circulation, where the results for operative embolectomy are frequently less than ideal.

Inferior vena cava filters--percutaneous insertion?

The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) among Chinese is much lower than in Caucasians. The total number of inferior vena cava (IVC) filters inserted in regional hospitals in Canada (about 700 beds in Toronto General Hospital) and Hong Kong (about 1,250 beds in Pamela Youde Nethersole Eastern Hospital) also reflects this. Thirty-six IVC filters were deployed in Toronto General Hospital, compared to 8 IVC filters inserted in Pamela Youde Nethersole Eastern Hospital from August 1997 to September 1998. Despite this, the physician may encounter patients with thromboembolic disease who require inferior vena cava interruption. The usual indication will be pulmonary embolism with contraindications to, or failure or complications of, anticoagulation therapy. It is important for angiographers to be familiar with the technique of percutaneous insertion of IVC filters. The types of IVC filters, techniques of insertion and guidelines relating to the choice of a filter would be discussed.

Salvage of the carotid artery with covered stent after perforation with dialysis sheath. A case report.

We present a rare case of carotid tear caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA). This was treated by placement of a covered stent-graft in the CCA over the puncture site. This treatment achieved hemostasis while preserving the carotid artery with good outcome. The technical details are presented and the relevant literature regarding treatment of carotid blowout syndrome is discussed. This case suggests that placement of a covered stent-graft is a good option not only for the "usual" blowout syndrome due to head and neck tumors, but also for treatment of iatrogenic injury to the carotid artery.

Noncoronary vascular stenting.

The aim of this report is to review the current state of the art with respect to noncoronary vascular stenting. A review of the literature was performed, examining the historical aspects of stent design and usage, as well as the currently available designs and their respective functions. When appropriate, we note our personal experience with stent placement in each anatomic site. Currently available stents take many forms: balloon-expandable, self-expanding, and shape-memory alloy. Varied design modifications have been made to maximize the open area, to limit the surface area of the prosthesis, to increase (or decrease) flexibility, and to increase (or decrease) stent plasticity and elasticity. Modifications to minimize thrombogenicity are also underway. The clinical uses of the currently available stents in multiple anatomic locations will be discussed. Intravascular stents are an addition to the arsenal available for prolonging blood vessel patency.

Salvage of in situ femoropopliteal and femorotibial saphenous vein bypass with interventional radiology.

Arteriovenous fistulas and late graft stenoses are well-known potential causes of in situ saphenous vein bypass failure. Three patients are described who had one or both of these complications postoperatively (early and late). Two techniques are described that can be performed at the time of arteriography to save a functioning bypass.

Fibrinolytic therapy in peripheral arterial grafts utilizing the "crossed two catheter" technique.

Direct puncture of a thrombosed lower extremity bypass graft may be the only angiographic access to the graft when it cannot be opacified or cannulated by conventional angiographic techniques. In 1 patient, fibrinolytic therapy was performed from this approach using the "crossed two catheter" technique previously described for thrombosed dialysis grafts.

Urethral diverticula in the adult female.

Urethral diverticulum in the adult female is an uncommon lesion which is practically ignored in the radiologic literature. The important symptom is incontinence. Because there is such poor clinical differentiation between stress incontinence, urgency incontinence, and post-void dribbling incontinence, we feel that any patient with incontinence that is not classical stress incontinence or of a neurologic cause should be investigated for urethral diverticulum. Six such patients plus one patient with a false positive panendoscopic examination are presented. Our method of examination with cinefluorography and conventional spot filming is explained. The urethrographic examination was found to be more reliable than the panendoscopic examination. When a discrepancy occurs, further studies are indicated.