Society of Interventional Radiology Research Reporting Standards for Genicular Artery Embolization.

Genicular artery embolization (GAE) is an emerging, minimally invasive therapy to address the global burden of knee osteoarthritis (OA) and the unmet needs for medically refractory disease. Although total knee arthroplasty has been a standard intervention for severe cases, GAE is developing into a promising alternative, particularly for patients ineligible for or unwilling to undergo surgery. GAE targets the inflammatory cascade underlying OA pathophysiology by arresting neoangiogenesis and preventing pathological neoinnervation, offering potential pain relief. Although early studies have established safety and short-term effectiveness, ensuing studies are needed to validate long-term safety, durability, and comparative effectiveness and to optimize patient selection, embolic agent selection, and administration techniques. Standardized reporting guidelines are therefore essential to enhance transparency and reproducibility across clinical trials, facilitating data aggregation and comparison. This Society of Interventional Radiology (SIR)-endorsed reporting standards consensus document provides a framework to harmonize future research efforts and to improve the interpretation of outcomes.

Multidisciplinary Delphi Consensus on Safety of Combining Transarterial Radioembolization with Yttrium-90 Microspheres with Systemic Anticancer Agents for the Treatment of Liver Malignancy.

PURPOSE: To provide guidance, via multidisciplinary consensus statements, on the safety interactions between systemic anticancer agents (such as radiosensitizing chemotherapy, immunotherapy, targeted therapy, and peptide receptor radionuclide therapy) and transarterial radioembolization (TARE) with yttrium-90 (90Y)-labeled microspheres in the treatment of primary and metastatic liver malignancies. MATERIALS AND METHODS: A literature search identified 59 references that informed 26 statements on the safety of 90Y TARE combined with systemic therapies. Modified Delphi method was used to develop consensus on statements through online anonymous surveys of the 12 panel members representing the fields of interventional radiology, medical oncology, surgical oncology, hepatology, and pharmacy, focusing on hepatocellular carcinoma (HCC), metastatic colorectal cancer (mCRC), neuroendocrine tumors, metastatic breast cancer, and intrahepatic cholangiocarcinoma. RESULTS: High-level evidence was limited. Level 1 data in patients with mCRC suggest that some radiosensitizing chemotherapies (eg, oxaliplatin) require temporary dose reduction when used concomitantly with 90Y TARE, and some targeted therapies (eg, vascular endothelial growth factor inhibitors and antiangiogenic tyrosine kinase inhibitors) should be avoided for at least 4 weeks before 90Y TARE. In patients with HCC, the feasibility of 90Y TARE and immunotherapy has been demonstrated with Level 4 evidence. Data are more limited for other primary and secondary liver malignancies, and consensus statements were driven by expert opinion (Level 5). CONCLUSIONS: Given the absence of evidence-based guidelines on the safety of 90Y TARE in combination with systemic anticancer therapy, these consensus statements provide expert guidance on the potential risks when considering specific combinations.

Real-world data to support post-market safety and performance of embolization coils: evidence generation from a medical device manufacturer and data institute partnership.

BACKGROUND: Recognizing the limitations of pre-market clinical data, regulatory authorities have embraced total product lifecycle management with post-market surveillance (PMS) data to assess medical device safety and performance. One method of proactive PMS involves the analysis of real-world data (RWD) through retrospective review of electronic health records (EHR). Because EHRs are patient-centered and focused on providing tools that clinicians use to determine care rather than collecting information on individual medical products, the process of transforming RWD into real-world evidence (RWE) can be laborious, particularly for medical devices with broad clinical use and extended clinical follow-up. This study describes a method to extract RWD from EHR to generate RWE on the safety and performance of embolization coils. METHODS: Through a partnership between a non-profit data institute and a medical device manufacturer, information on implantable embolization coils' use was extracted, linked, and analyzed from clinical data housed in an electronic data warehouse from the state of Indiana's largest health system. To evaluate the performance and safety of the embolization coils, technical success and safety were defined as per the Society of Interventional Radiology guidelines. A multi-prong strategy including electronic and manual review of unstructured (clinical chart notes) and structured data (International Classification of Disease codes), was developed to identify patients with relevant devices and extract data related to the endpoints. RESULTS: A total of 323 patients were identified as treated using Cook Medical Tornado, Nester, or MReye embolization coils between 1 January 2014 and 31 December 2018. Available clinical follow-up for these patients was 1127 ± 719 days. Indications for use, adverse events, and procedural success rates were identified via automated extraction of structured data along with review of available unstructured data. The overall technical success rate was 96.7%, and the safety events rate was 5.3% with 18 major adverse events in 17 patients. The calculated technical success and safety rates met pre-established performance goals (≥ 85% for technical success and ≤ 12% for safety), highlighting the relevance of this surveillance method. CONCLUSIONS: Generating RWE from RWD requires careful planning and execution. The process described herein provided valuable longitudinal data for PMS of real-world device safety and performance. This cost-effective approach can be translated to other medical devices and similar RWD database systems.

Ultrasound-guided perineal laser ablation versus prostatic arterial embolization for benign prostatic hyperplasia: two similar short-term efficacies.

BACKGROUND: There are many ways to treat prostatic hyperplasia; these are currently more inclined to minimally invasive treatment. We mainly compared the differences between two treatment methods， ultrasound-guided transperineal laser ablation (US-TPLA) and prostatic artery embolization (PAE). PURPOSE: To evaluate the efficacy and safety of US-TPLA and PAE in the treatment of benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: The clinical information for 40 patients with BPH admitted to our hospital between June 2018 and January 2021 were retrospectively analyzed. The changes in International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), prostate volume (PV), and the incidence of complications were compared between groups. RESULTS: The IPSS (P < 0.001; P < 0.001), QoL (P < 0.001; P < 0.001), Qmax (P < 0.001; P < 0.001), PVR (P < 0.001; P < 0.001), and PV (P < 0.001; P < 0.001) at three and six months after US-TPLA and PAE improved with respect to those before surgery. There was no significant difference in IPSS (P = 0.235; P = 0.151), QoL (P = 0.527; P = 0.294), Qmax (P = 0.776; P = 0.420), PVR (P = 0.745; P = 0.607), and PV (P = 0.527; P = 0.573) between the groups at three and six months after surgery. No serious complications occurred in either group. CONCLUSION: US-TPLA and PAE seem to have a similar short-term efficacy. The efficacy of the two procedures is comparable, and neither is associated with serious complications. US-TPLA and PAE are both effective complementary measures for the treatment of BPH.

AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review.

DESCRIPTION: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS: This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.

Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel.

PURPOSE: To summarize the Society of Interventional Radiology Foundation's Research Consensus Panel development of a research agenda on prostate artery embolization (PAE). MATERIALS AND METHODS: PAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data. RESULTS: Final consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data. CONCLUSIONS: Level 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.

A child in shock: carotid blowout syndrome.

Paediatricians commonly encounter neck lumps during their routine clinical practice; vascular abnormalities, such as (pseudo)aneurysms, are a rare cause of these. Pseudoaneurysms of the carotid artery in children are usually the result of blunt or penetrating trauma, infection or vasculitis/connective tissue disorders. They can present with a variety of symptoms including neck pain, as a pulsatile neck mass or with compressive symptoms (for example, cranial nerve palsies or dyspnoea). Pseudoaneurysms carry a risk of rupture in which case they are fatal, unless immediate treatment is provided.We report a 17-month-old male child with idiopathic carotid artery blowout syndrome presenting with acute oropharyngeal haemorrhage leading to asystolic cardiac arrest. He was successfully resuscitated and emergency embolisation controlled the bleeding. Despite extensive left hemispheric infarct, he has survived.Carotid artery blowout syndrome needs to be recognised as a potential cause of major haemorrhage in childhood. The purpose of this case report is to remind readers of the differential diagnosis and work-up of a child presenting with a neck lump, to highlight important aspects of the acute management of major haemorrhage and massive blood transfusion in paediatrics, to describe the aetiology, presentation and management of carotid artery pseudoaneurysm in children and to discuss long term rehabilitation in patients with consequent neurological sequelae (including the need for input from multiple specialty teams).

A systematic review and meta-analysis of the management of visceral artery aneurysms.

BACKGROUND: The evidence supporting management decisions of visceral artery aneurysms (VAAs) is sparse. Practice guidelines are needed to help patients and surgeons choose between endovascular and open surgery approaches. METHODS: We searched MEDLINE, EMBASE, Cochrane databases, and Scopus for studies of patients with VAAs. Studies were selected and appraised by pairs of independent reviewers. Meta-analysis was performed when appropriate. RESULTS: We included 80 observational studies that were mostly noncomparative. Data were available for 2845 aneurysms, comprising 1279 renal artery, 775 splenic artery, 359 hepatic artery, 226 pancreaticoduodenal and gastroduodenal arteries, 95 superior mesenteric artery, 87 celiac artery, 15 jejunal, ileal and colic arteries, and 9 gastric and gastroepiploic arteries. Differences in mortality between open and endovascular approaches were not statistically significant. The endovascular approach was used more often by surgeons. The endovascular approach was associated with shorter hospital stay and lower rates of cardiovascular complications but higher rates of reintervention. Postembolization syndrome rates ranged from 9% (renal) to 38% (splenic). Coil migration ranged from 8% (splenic) to 29% (renal). Otherwise, access site complication were low (<5%). Pseudoaneurysms tended to have higher mortality and reintervention rates. CONCLUSIONS: This systematic review provides event rates for outcomes important to patients with VAAs. Despite the low certainty warranted by the evidence, these rates along, with surgical expertise and anatomic feasibility, can help patients and surgeons in shared-decision making.

Splenic Embolization After Trauma: An Opportunity to Improve Best Immunization Practices.

BACKGROUND: The spleen is the second most commonly injured solid organ during blunt abdominal trauma. Although total splenectomy is frequently performed for injury, splenic rupture can also be managed by splenic embolization. For these patients, current Advisory Committee on Immunization Practices (ACIP) recommendations indicate that if 50% or more of the splenic mass is lost, patients should be treated as though they are asplenic. We have previously demonstrated that compliance with ACIP guidelines regarding immunization after splenectomy is poor. Compliance with vaccination in the setting of splenic embolization for trauma is unknown and we hypothesized patients would not receive the recommended immunizations. MATERIALS AND METHODS: All admissions at our level 1 trauma center requiring splenic embolization secondary to traumatic injury between January 1, 2010, and November 1, 2015, were reviewed. Demographic and injury data, dates and imaging of splenic embolizations, immunization documentation, subsequent vaccination boosters received, and outcomes were collected from the medical record. The proportion of spleen embolized was estimated by review of angiographic imaging using an established method. RESULTS: Nine thousand nine hundred sixty-five trauma patients were admitted during the period studied. Nineteen patients met inclusion and exclusion criteria. Median age of the patient population was 35 y, 85% were male, and median injury severity score was 28. Of these, 15 patients underwent a splenic embolization, in which 50% or more of their splenic mass was lost through embolization. Eight patients received at least one immunization before discharge. Six received initial immunizations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, while three received only the initial immunization against S pneumoniae. None of the 15 patients received any ACIP-recommended booster. Of the four patients having less than 50% of their spleen embolized, three wrongly received immunization against encapsulated organisms before hospital discharge. CONCLUSIONS: Trauma patients undergoing splenic embolization at our institution receive postsplenectomy immunizations incorrectly and had no recorded booster vaccines. We speculate that this is common among the U.S. trauma centers. Review of immunization practices in our trauma and nontrauma patient populations is underway in our health system to improve the care of these patients, and our experience may serve as a guide for other centers to reduce complications associated with asplenia.

Efficacy and Safety of Prostatic Arterial Embolization: Systematic Review with Meta-Analysis and Meta-Regression.

PURPOSE: This study attempted to overcome the limitations of previous systematic reviews to determine the overall treatment efficacy and safety of prostatic arterial embolization compared with standard therapy. MATERIALS AND METHODS: Meta-analyses were done of randomized, controlled and single group trials. Meta-regression analysis of the moderator effect was performed with single group analysis. The outcomes measured were mean changes in I-PSS (International Prostate Symptom Score), quality of life, maximal urinary flow rate, prostate volume, post-void residual volume and prostate specific antigen. Adverse events were compared as proportional differences between the embolization group and groups receiving other therapies in comparative studies. RESULTS: A total of 16 studies met our selection criteria and were included in the meta-analysis. Three studies were comparative and included a total of 297 subjects, including 149 in the experimental groups and 148 in the control groups. The other 13 studies were noncomparative and included a total of 750 experimental subjects. Pooled overall standardized mean differences for embolization in I-PSS, maximal urinary flow rate and prostate volume were significantly impaired in the experimental vs control groups. Overall weighted mean differences for all outcomes except prostate specific antigen were significantly improved from baseline by embolization treatment in noncomparative studies. Sensitivity analysis of study duration showed that all outcome measurements did not differ before vs after 6 months. CONCLUSIONS: Although there is growing evidence of the efficacy and safety of prostatic arterial embolization for benign prostatic hyperplasia, this systematic review using meta-analysis and meta-regression showed that prostatic arterial embolization should still be considered an experimental treatment modality.

Patient radiation doses and reference levels in pediatric interventional radiology.

OBJECTIVES: To describe, in a multicentric paediatric population, reference levels (RLs) for three interventional radiological procedures. METHODS: From January 2012 to March 2015, children scheduled for an interventional radiological procedure in two French tertiary centres were retrospectively included and divided into four groups according to age: children younger than 2 years (A1), aged 2-7 years (A5), 8-12 years (A10) and 13-18 years (A15). Three procedures were identified: cerebral digital subtraction angiography (DSA), brain arteriovenous malformation (bAVM) embolization, and head and neck superficial vascular malformation (SVM) percutaneous sclerotherapy. Demographic and dosimetric data, including dose area product (DAP), were collected. RESULTS: 550 procedures were included. For DSA (162 procedures), the proposed RL values in DAP were 4, 18, 12 and 32 Gy∙cm2 in groups A1, A5, A10 and A15, respectively. For bAVM embolization (258 procedures), values were 33, 70, 105 and 88 Gy∙cm2 in groups A1, A5, A10 and A15, respectively. For SVM sclerotherapy (130 procedures), values were 350, 790, 490 and 248 mGy∙cm2 in groups A1, A5, A10 and A15, respectively. CONCLUSION: Consecutive data were available to permit a proposal of reference levels for three major paediatric interventional radiology procedures. KEY POINTS: • We determined reference levels (RLs) for bAVM embolization, DSA and SVM sclerotherapy. • The proposed RLs will permit benchmarking practice with an external standard. • The proposed RLs by age may help to develop paediatric dose guidelines.

Invasive therapies for primary postpartum haemorrhage: a population-based study in France.

OBJECTIVE: To describe the characteristics, management, and outcomes of women undergoing invasive therapies for primary postpartum haemorrhage (PPH). DESIGN: A population-based observational study. SETTING: All 106 maternity units of six French regions. POPULATION: A total of 146 781 women delivering between 2004 and 2006. METHODS: Prospective identification of women with PPH managed with invasive therapies, including uterine suture, pelvic vessel ligation, arterial embolisation, and hysterectomy. MAIN OUTCOME MEASURES: Rate of use and failure rate of invasive therapies, with 95% confidence intervals (95% CIs). RESULTS: An invasive therapy was used in 296 of 6660 women with PPH (4.4%, 95% CI 4.0-5.0), and in 0.2% of deliveries (95% CI 0.18-0.23). A hysterectomy was performed in 72/6660 women with PPH (1.1%, 95% CI 0.8-1.4%), and in 0.05% of deliveries (95% CI 0.04-0.06). A conservative invasive therapy was used in 262 women, including 183 (70%) who underwent arterial embolisation and 79 (30%) who had conservative surgery as the first-line therapy. Embolisation was more frequently used after vaginal than caesarean delivery, and when arterial embolisation was available on site. The failure rate of conservative invasive therapies was 41/262 (15.6%, 95% CI 11.5-20.6) overall, and was higher after surgical than after embolisation procedures, in particular for vaginal deliveries. CONCLUSIONS: Both maternal mortality as a result of obstetric haemorrhage and the rate of invasive therapies used for PPH are high in France. These findings suggest flaws in the initial management of PPH and/or the inadequate use of invasive procedures. TWEETABLE ABSTRACT: Maternal mortality as a result of haemorrhage and the rate of invasive therapies used for PPH are high in France.

Role of hepatic intra-arterial therapies in metastatic neuroendocrine tumours (NET): guidelines from the NET-Liver-Metastases Consensus Conference.

OBJECTIVES: Liver metastasis from a neuroendocrine tumour (NET) represents a significant clinical entity. A multidisciplinary group of experts was convened to develop state-of-the-art recommendations for its management. METHODS: Peer-reviewed published reports on intra-arterial therapies for NET hepatic metastases were reviewed and the findings presented to a jury of peers. The therapies reviewed included transarterial embolization (TAE), transarterial chemoembolization (TACE) and radioembolization (RE). Two systems were used to evaluate the level of evidence in each publication: (i) the US National Cancer Institute (NCI) system, and (ii) the GRADE system. RESULTS: Eighteen publications were reviewed. These comprised 11 reports on TAE or TACE and seven on RE. Four questions posed to the panel were answered and recommendations offered. CONCLUSIONS: Studies of moderate quality support the use of TAE, TACE and RE in hepatic metastases of NETs. The quality and strength of the reports available do not allow any modality to be determined as superior in terms of imaging response, symptomatic response or impact on survival. Radioembolization may have advantages over TAE and TACE because it causes fewer side-effects and requires fewer treatments. Based on current European Neuroendocrine Tumor Society (ENETS) Consensus Guidelines, RE can be substituted for TAE or TACE in patients with either liver-only disease or those with limited extrahepatic metastases.

Type II endoleak: conservative management is a safe strategy.

OBJECTIVE: Type II endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR); however, its natural history is unclear. The aim of this study was to examine the incidence and outcomes of type II endoleak, at a single institution after EVAR. METHODS: A total of 904 consecutive patients who underwent EVAR between September 1995 and July 2013 at a single centre were entered onto a prospective database. All patients were followed up by duplex ultrasound (DUSS). Patients who developed type II endoleak were compared for preoperative demographics, mortality, and sac expansion. RESULTS: A total of 175(19%) patients developed type II endoleak over a median follow-up of 3.6 years (1.5-5.9 years); 54% of type II endoleaks spontaneously resolved within 6 months (0.25-1.2 years). No difference was found in preoperative demographics or choice of endograft between the two groups. Survival was significantly higher in the group with type II endoleak (94.1% vs. 85.6%; p = .01) and this effect was most pronounced in those with late type II endoleaks (97.7% vs. 85.6% p = .004). No difference was seen in aneurysm-related mortality or rate of type I endoleak between the two groups. Freedom from sac expansion (>5 mm from preoperative diameter) was significantly lower in the group of patients with type II endoleak (82.5% vs. 93.2%, p = .0001); however, at a threshold of >10 mm from preoperative diameter no difference was seen. CONCLUSIONS: Patients with isolated type II endoleak demonstrate equivalent aneurysm-related mortality and an improved survival.

Contemporary management of spinal AVFs and AVMs: lessons learned from 110 cases.

OBJECT: Spinal arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs) are rare, complex spinal vascular lesions that are challenging to manage. Recently, understanding of these lesions has increased thanks to neuroimaging technology. Published reports of surgical results and clinical outcome are limited to small series. The authors present a large contemporary series of patients with spinal AVFs and AVMs who were treated at Barrow Neurological Institute in Phoenix, Arizona. METHODS: Retrospective detailed review of a prospective vascular database was performed for all patients with spinal AVFs and AVMs treated between 2000 and 2013. Patient demographic data, AVF and AVM characteristics, surgical results, clinical outcomes, complications, and long-term follow-up were reviewed. RESULTS: Between 2000 and 2013, 110 patients (57 male and 53 female) underwent obliteration of spinal AVFs and AVMs. The mean age at presentation was 42.3 years (range 18 months-81 years). There were 44 patients with AVFs and 66 with AVMs. The AVM group included 27 intramedullary, 21 conus medullaris, 12 metameric, and 6 extradural. The most common location was thoracic spine (61%), followed by cervical (22.7%), lumbar (14.5%), and sacral (1.8%). The most common presenting signs and symptoms included paresis/paralysis (75.5%), paresthesias (60%), pain (51.8%), bowel/bladder dysfunction (41.8%), and myelopathy (36.4%). Evidence of rupture was seen in 26.4% of patients. Perioperative embolization was performed in 42% of patients. Resection was performed in 95 patients (86.4%). Embolization alone was the only treatment in 14 patients (12.7%). One patient was treated with radiosurgery alone. Angiographically verified AVF and AVM obliteration was achieved in 92 patients (83.6%). At a mean follow-up duration of 30.5 months (range 1-205 months), 43 patients (97.7%) with AVFs and 57 (86.4%) with AVMs remained functionally independent (McCormick Scale scores ≤ 2). Perioperative complications were seen in 8 patients (7%). No deaths occurred. Temporary neurological deficits were observed in 27 patients (24.5%). These temporary deficits recovered 6-8 weeks after treatment. Recurrence was identified in 6 patients (13.6%) with AVFs and 10 (15.2%) with AVMs. CONCLUSIONS: Spinal AVFs and AVMs are complex lesions that should be considered for surgical obliteration. Over the last several decades the authors have changed surgical strategies and management to achieve better clinical outcomes. Transient neurological deficit postoperatively is a risk associated with intervention; however, clinical outcomes appear to exceed the natural history based on patients' ability to recover during the follow-up period. Due to the recurrence rate associated with these lesions, long-term follow-up is required.

Clipping versus coiling for intracranial aneurysms.

BACKGROUND AND PURPOSE: The aim of this study was to compare results of clipping and coiling for aneurysms of the anterior circle of Willis. Previous studies have not identified a clear superiority of one method over the other. MATERIAL AND METHODS: The study group included 165 consecutive patients. The assessment took into account the risk of death, neurological status according to the scale of the GOS and mRS, the incidence of early complications and quality of life measured by own surveys and questionnaire EORTC QLQ-C30 v. 3.0. RESULTS: Mean follow-up was more than four years. Early and late results of treatment after embolization and clipping for all patients did not differ. Evaluation of patients with bleeding aneurysms demonstrated better outcomes after embolization, however statistical significance was observed only in terms of symptomatic scale score of QLQ-C30 questionnaire (p=0.02). For patients with non-bleeding aneurysms better outcomes were obtained after clipping, but statistical significance was found only in the early results: more excellent results in GOS score at discharge (p<0.03) and fewer complications during hospitalization (p=0.02). CONCLUSIONS: Results of treatment after clipping and coiling do not differ in total for all patients, but differ depending on the presence of bleeding. Patients with bleeding aneurysms achieve better outcomes after coiling, and patients with non-bleeding aneurysms achieve better outcomes after clipping.

Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms.

BACKGROUND AND PURPOSE: Flow diversion has emerged as an important tool for the management of intracranial aneurysms. The purpose of this study was to compare flow diversion and traditional embolization strategies in terms of safety, efficacy, and clinical outcomes in patients with unruptured, large saccular aneurysms (≥10 mm). METHODS: Forty patients treated with the Pipeline Embolization Device (PED) were matched in a 1:3 fashion with 120 patients treated with coiling based on patient age and aneurysm size. Fusiform and anterior communicating artery aneurysms were eliminated from the analysis. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. RESULTS: There were no differences between the 2 groups in terms of patient age, sex, aneurysm size, and aneurysm location. The rate of procedure-related complications did not differ between the PED (7.5%) and the coil group (7.5%; P=1). At the latest follow-up, a significantly higher proportion of aneurysms treated with PED (86%) achieved complete obliteration compared with coiled aneurysms (41%; P<0.001). In multivariable analysis, coiling was an independent predictor of nonocclusion. Retreatment was necessary in fewer patients in the PED group (2.8%) than the coil group (37%; P<0.001). A similar proportion of patients attained a favorable outcome (modified Rankin Scale, 0-2) in the PED group (92%) and in the coil group (94%; P=0.8). CONCLUSIONS: The PED provides higher aneurysm occlusion rates than coiling, with no additional morbidity and similar clinical outcomes. These findings suggest that the PED might be a preferred treatment option for large unruptured saccular aneurysms.