Vascular complication after sacrospinous ligament fixation with uterine preservation.

AIM OF THE VIDEO: Sacrospinous ligament fixation (SSLF) is a minimally invasive transvaginal procedure for correcting apical prolapse. Amongst perioperative complications, life-threatening hemorrhage has a reported occurrence rate ranging from 0.2 % to 2 %. We present a case of arterial hemorrhage following SSLF and a multispecialty approach to its successful management. METHODS: The video demonstrates the development of an unexpected progressive postoperative hematoma following left-side sacrospinous hysterocolpopexy via the anterior approach, despite minimal intraoperative bleeding. The mechanism of formation of the hematoma could have been laceration of an aberrant vaginal branch of the inferior vesical artery secondary to pulling the anchor which is tied off at the cervix after closure. To treat these patients effectively, it is essential for the surgeon to make a timely diagnosis, and in our patient, embolization of the inferior vesical artery provided a safe and effective treatment for the pelvic hemorrhage that eliminated the need for an invasive surgical intervention. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Pelvic vessel embolization can provide an effective, minimally invasive alternative to surgical re-exploration.

Quantification of coronary artery motion and internal risk volume from ECG gated radiotherapy planning scans.

BACKGROUND: Radiotherapy for carcinoma of breast and thoracic structures involves inadvertent radiation to heart and coronary arteries (CA). Coronary artery stenosis in high radiation dose segments has been documented. Cardiac and respiratory motion induced displacement of CA and internal risk volume (IRV) margin remains inadequately quantified. MATERIAL AND METHODS: Twenty cases of carcinoma breast, lung and lung metastasis were enrolled in this study. ECG gated intravenous contrast enhanced computed tomography (CECT) scans were performed in inspiratory breath hold (IBH) and expiratory breath hold (EBH). The images were segregated into inspiratory systole (IS), inspiratory diastole (ID), expiratory systole (ES) and expiratory diastole (ED) sets. Left anterior descending (LAD), limited segment of LAD close to chest wall (short LAD), right coronary artery (RCA), Left circumflex artery (LCX) and left ventricle (LV) were delineated in all four sets. Mean displacements in systole versus diastole and inspiration versus expiration were calculated in three co-ordinates [anterio-posterior (Z), left-right (X) and cranio-caudal (Y)]. RESULTS: Mean of displacement (mm) between systole and diastole (IS versus ID; and ES versus ED) in X, Y, Z co-ordinates were: LAD 3.0(±1.6), 2.8(±1.5), 3.6(±2.0); Short-LAD 3.0(±1.1), 0.8(±0.4), 2.4(±0.6); LV 2.4(±1.6), 1.7(±1), 5.0(±1.5); LCX 4.9(±1.6), 2.9(±1.3), 5.1(±1.9); RCA 6.6(±2.2), 3.6(±2.1), 5.9(±2.2). Mean displacement between inspiration and expiration (IS versus ES; and ID versus ED) in X, Y, Z axes were: LAD 3.3(±1.5), 8.0(±3.4), 3.8(±1.8); Short-LAD 2.7(±1), 12.2(±4.4), 3.3(±1.5); LV 2.9(±1.4), 9.8(±3.3), 4.7(±1.9); LCX 2.9(±.8), 9.7(±3.2), 6.2(±2.5); RCA 2.6(±1.3), 7.6(±2.5), 3.8(±1.7). CONCLUSION: Radial (RM), cranio-caudal margin (CC) of 7mm, 4mm in breath-hold radiotherapy whereas RM, CC of 7mm, 13mm respectively in free breath radiotherapy will cover the range of motions of CA, LV and can be recommended as IRV for these structures.