RESUMEN
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
RESUMEN
BACKGROUND: The 3D-REAL-IR MRI sequence allows for an in vivo visualization of endolymphatic hydrops. Qualitative assessment methods of the severity of vestibular and cochlear hydrops are the most commonly used. METHODS: A quantitative volumetric measurement of vestibular EH in patients with definite unilateral Ménière's disease using the 3D-REAL-IR sequence and the calculation of the endolymphatic ratio (ELR) was intended. RESULTS: Volumetric calculations of the vestibules, vestibular endolymph and vestibular ELR are performed in 96 patients with unilateral Ménière's disease and correlated with classic qualitative grading scales. CONCLUSIONS: Quantitative volumetric measurement of vestibular hydrops using the 3D-REAL-IR sequence is feasible and reproducible in daily clinical practice. Vestibular ELR values exceeding 60% defined radiologically significant vestibular hydrops, while values below 30% defined radiologically non-significant vestibular hydrops.
Asunto(s)
Embolización Terapéutica/métodos , Enbucrilato/administración & dosificación , Procedimientos Endovasculares/métodos , Ovario/irrigación sanguínea , Ovario/cirugía , Dolor Pélvico/terapia , Femenino , Humanos , Dolor Pélvico/diagnóstico por imagen , Estudios Prospectivos , Síndrome , Útero/irrigación sanguínea , Várices/terapiaRESUMEN
PURPOSE: To assess the clinical outcomes of transcatheter arterial embolization (TAE) for secondary stiff shoulder (SSS). MATERIALS AND METHODS: This is a retrospective analysis of prospectively collected data performed between January 2017 and December 2019. This study comprised 25 patients (20 women and 5 men; median age, 49 years; range 27-59) with SSS resistant to conservative management during at least 3 months. The median time of stiffness was 12 months. The etiology of SSS was postoperative in 14 patients (56%) and posttraumatic in the remaining 11 patients (44%). Periods of immobilization in all patients were associated. TAE was performed, and technical aspects, adverse events, changes for pain, and physical examination before and 6 months after TAE were assessed. RESULTS: Abnormal vessels were observed in 20 of 25 (80%) of the procedures. Transitory cutaneous erythema was noted in 4 patients treated after TAE. Significant differences were observed in the median pain visual analog scale reduction between before and 6 months after TAE (8 vs 2, P < .001). Shoulder mobility significantly improved in both flexion and abduction degrees between before and at 6 months after TAE in (70° vs 150°; P < .001). No symptoms of recurrence appeared. CONCLUSIONS: TAE can result in pain reduction and mobility improvement in patients with SSS refractory to conservative therapy.
Asunto(s)
Bursitis/terapia , Embolización Terapéutica , Dolor de Hombro/terapia , Adulto , Bursitis/diagnóstico por imagen , Bursitis/etiología , Bursitis/fisiopatología , Embolización Terapéutica/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Dolor de Hombro/diagnóstico por imagen , Dolor de Hombro/etiología , Dolor de Hombro/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate the mid-term clinical outcomes of transcatheter arterial embolization (TAE) for adhesive capsulitis (AC) resistant to medical treatments. MATERIALS AND METHODS: This is a prospective analysis performed between February 2016 and February 2020. Inclusion criteria for TAE were shoulder pain, restriction of movement and no response to conservative treatment for at least 3 months. Demographic variables, risk factors, technical aspects, adverse events, changes by visual analogue scale (VAS) for pain and physical examination before and after TAE were assessed. RESULTS: This study included 40 patients with AC (35 women and 5 men; mean age 50 ± 9 years old). Abnormal vessels were observed in 31/40 (77.5%) procedures. As embolic agent, imipenem/cilastatin was used. The mean follow-up was 21.2 ± 10.5 months. Significant differences were obtained in terms of pain reduction before and 6 months after TAE with the median visual analogue scale (VAS) of 8 vs. 0.5, P = 0.0001. Substantial differences were found regarding mobility in flexion and abduction before and 6 months after embolization, respectively (79.5° ± 18.5° vs. 133° ± 24.5°, P = 0.0001; 72.4° ± 18.8° vs. 129.7° ± 27.9°, P = 0.0001). No complications occurred. Complete recovery was obtained in 37/40 (92.5%) patients and partial recovery in 2/40 (5%). No clinical recurrence appeared. CONCLUSIONS: Clinical results of transcatheter arterial embolization with imipenem/cilastatin are effective and stable in the mid-term follow-up for patients presenting with AC resistant to conservative treatments.
Asunto(s)
Bursitis/terapia , Embolización Terapéutica/métodos , Articulación del Hombro , Adulto , Anciano , Bursitis/complicaciones , Tratamiento Conservador , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Dolor de Hombro/etiología , Dolor de Hombro/terapia , Resultado del TratamientoRESUMEN
PURPOSE: To report preliminary experience with angiomyolipoma (AML) transcatheter arterial embolization using ethylene vinyl alcohol (EVOH) copolymer liquid embolic agent. MATERIALS AND METHODS: Embolization was performed in 22 consecutive patients (mean age, 53.5 y; 16 women and 6 men) for symptomatic AMLs or AMLs > 4 cm. Mean AML size before treatment was 7 cm (range, 3.5-13 cm). Superselective embolization of all lesions using microcatheters was performed; EVOH copolymer was the only embolic agent used. Data collected included volume of EVOH copolymer used, AML size before and after treatment, bleeding control, rebleeding, renal function, and complications. RESULTS: Twenty-seven embolizations were performed for 25 AMLs. In 3 patients, embolization of 2 different AMLs was performed. A mean volume of 2.5 mL (range, 1-8 mL) of 6% EVOH copolymer was administered per lesion. Of embolizations, 17 (63%) were elective, and 10 (37%) were urgent. For urgent cases, primary and secondary bleeding control rates were 80% and 100%, respectively. Two urgent embolizations had early rebleeding from different previously treated vessels and a successful second embolization was performed. Mean follow-up time was 37.7 months (range, 5-124 months). Rate of postembolization syndrome was 18.5%. Mean size reduction of 45.7% ± 21.5 over the maximum length of the AML before treatment was achieved. No AML regrowth occurred during follow-up. Minor and major complication rates were 7.4% and 0%, respectively. No rebleeding and no renal function impairment occurred during follow-up. CONCLUSIONS: AML embolization with EVOH copolymer is feasible, safe, and effective. EVOH copolymer could be another embolic option for AML treatment.
Asunto(s)
Angiomiolipoma/terapia , Embolización Terapéutica/métodos , Neoplasias Renales/terapia , Polivinilos/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Preoperative planning of deep inferior epigastric perforator (DIEP) flaps has become increasingly important in radiology services as multidetector CT angiography (CTA) has been proven to be the technique of choice. We aim to optimise the process, checking the value of the "Navarra criteria," assessing radiological and surgical concordance. METHODS: Preoperative CTA was obtained in 105 DIEP flaps involving 101 women (mean age 49.1 years). A main perforator pedicle and an alternative were chosen, applying a modification of the "Navarra criteria," assessing the correlation between the main perforator chosen by the radiologist and the one that was ultimately used to perform the flap using the Kappa index. RESULTS: In 100 of the 105 DIEP flaps (95.2%), the perforator pedicles chosen were ultimately used to raise the flap. Four of the perforator pedicles that were not used were dismissed due to avoidable errors in the radiological approach. Concordance was very high, with a Kappa index of 0.93 (95% CI: 0.87-0.99). CT room time was less than 12 minutes, and reading time was 10 minutes. CONCLUSIONS: The application of the "Navarra criteria" in preoperative planning of DIEP flaps improves radiological and surgical concordance as well as the reading process. KEY POINTS: DIEP flap is one of the best techniques for breast reconstruction. Preoperative planning is essential in DIEP flaps. CTA is the best option for the preoperative planning of DIEP flaps. "Navarra criteria" allow radiologists to choose the best perforator to form flaps. Modified "Navarra criteria" improves radiological and surgical concordance.
Asunto(s)
Angiografía por Resonancia Magnética/métodos , Mamoplastia/métodos , Tomografía Computarizada Multidetector/métodos , Colgajo Perforante/irrigación sanguínea , Cuidados Preoperatorios/métodos , Recto del Abdomen/trasplante , Ultrasonografía Doppler en Color/métodos , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
PURPOSE: To evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, California) as the primary treatment for acute and massive lower gastrointestinal bleeding (LGIB). MATERIALS AND METHODS: Between January 2008 and October 2013, all patients with focal massive LGIB who were treated by embolization were retrospectively analyzed. The study was approved by the hospital's ethics committee; informed consent was obtained in all cases. Onyx was chosen as the embolic agent in all cases in an intention-to-treat fashion. Embolization was indicated in 31 consecutive patients (mean age, 80 y ± 11.1). Multidetector computed tomography and digital subtraction angiography were performed in all patients. RESULTS: Active bleeding was detected in all cases. A colonoscopy was performed in 11 patients. The correlation between multidetector computed tomography and angiography findings was 96.7%. The causes of bleeding were diverticula in 15 patients, iatrogenic in 7 patients, neoplasia in 3 patients, hemorrhoids in 2 patients, angiodysplasia in 2 patients, and unknown in 2 patients. Embolization was not possible in one patient, who required urgent left hemicolectomy. The technical success rate was 93.5%. The embolic material refluxed in one patient, causing an undesired embolization, without any clinical consequences. In the 30 patients who received embolization, the immediate bleeding control rate was 100%. Rebleeding at 30 days occurred in three patients (10%). There were no major complications, intestinal ischemia, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 23.7 months (range, 1-71 mo). CONCLUSIONS: Control of massive LGIB using superselective embolization with Onyx is feasible and safe.
Asunto(s)
Embolización Terapéutica/métodos , Hemorragia Gastrointestinal/terapia , Polivinilos/administración & dosificación , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Colonoscopía , Embolización Terapéutica/efectos adversos , Estudios de Factibilidad , Femenino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Humanos , Análisis de Intención de Tratar , Masculino , Tomografía Computarizada Multidetector , Polivinilos/efectos adversos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils. PURPOSE: To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment. MATERIAL AND METHODS: From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11-41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected. RESULTS: The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7-10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition. CONCLUSION: N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.
Asunto(s)
Embolización Terapéutica , Enbucrilato/uso terapéutico , Soluciones Esclerosantes/uso terapéutico , Escleroterapia , Varicocele/terapia , Adolescente , Adulto , Niño , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Varicocele/diagnóstico , Adulto JovenRESUMEN
Preoperative imaging of recipient-site vasculatur in autologous breast reconstruction may potentiate improved outcomes through the identification of individual variations in vascular architecture. There are a range of both normal and pathologic states which can substantially affect the internal mammary vessels in particular, and the identification of these preoperatively may significantly affect operative approach. There are a range of imaging modalities available, with ultrasound particularly useful, and computed tomography angiography (CTA) evolving as a useful option, albeit with radiation exposure. The benefits of CTA must be balanced against its risks, which include contrast nephrotoxicity and allergic reactions, and radiation exposure. The radiation risk with thoracic imaging is substantially higher than that for donor sites, such as the abdominal wall, with reasons including exposure of the contralateral breast to radiation (with a risk of contralateral breast cancer in this population 2 to 6 times higher than that of primary breast cancer, reaching a 20-year incidence of 15%), as well as proximity to the thyroid gland. Current evidence suggests that although many cases may not warrant such imaging because of risk, the benefits of preoperative CTA in selected patients may outweigh the risks of exposure, prompting an individualized approach.
Asunto(s)
Mamoplastia/métodos , Arterias Mamarias , Cuidados Preoperatorios/métodos , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler , Femenino , Colgajos Tisulares Libres , Humanos , Arterias Mamarias/anatomía & histología , Arterias Mamarias/diagnóstico por imagen , Arterias Mamarias/patología , Colgajo PerforanteRESUMEN
Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered.
Asunto(s)
Diagnóstico por Imagen , Planificación de Atención al Paciente , Colgajo Perforante/irrigación sanguínea , Procedimientos de Cirugía Plástica , Nalgas/irrigación sanguínea , Arterias Epigástricas , Humanos , Pierna/irrigación sanguínea , Vértebras Lumbares/irrigación sanguínea , Cuidados PreoperatoriosRESUMEN
BACKGROUND: Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject. METHODS: The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress. RESULTS: The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA. CONCLUSION: While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.
Asunto(s)
Microcirugia/métodos , Procedimientos de Cirugía Plástica/métodos , Cuidados Preoperatorios/métodos , Colgajos Quirúrgicos/irrigación sanguínea , Angiografía/métodos , Humanos , Angiografía por Resonancia Magnética , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler en ColorRESUMEN
We undertook a review of the anatomical changes of "choke" vessels between the internal thoracic artery (ITA) and deep inferior epigastric artery (DIEA), as highlighted by a case of aortoiliac occlusive disease (Leriche's syndrome), and discuss the physiological concepts observed with regard to surgical delay procedures within the abdominal wall performed prior to abdominal cutaneous free flaps and coronary artery bypass grafting. Computed tomographic angiography (CTA) was undertaken on a patient with a rare case of Leriche's syndrome and a literature review of over 200 references on the anatomy, physiology and clinical uses of choke vessels in the abdominal wall was undertaken. The CTA demonstrated that in patients with Leriche's syndrome, there is a marked dilatation of all ITA-DIEA pathways and increased flow through choke vessels. If these changes can be surgically replicated in the form of a delay procedure for patients seeking to undergo autologous breast construction, this could improve the outcomes of abdominal cutaneous free flaps and coronary artery bypass grafting. We accordingly propose three surgical methods for augmenting blood flow to the abdominal wall: a) ligation of the DIEA; b) ligation of the distal ITA; and c) creation of an arterio-venous fistulae in the DIEA. Our review of the literature confirmed the viability of these propositions. The dilatation of choke vessels in response to increased haemodynamic stress may thus be utilised to enhance blood supply to tissues prior to transfer and can be achieved through simple and minimally invasive methods.
Asunto(s)
Pared Abdominal/irrigación sanguínea , Arterias Epigástricas/diagnóstico por imagen , Síndrome de Leriche/diagnóstico por imagen , Arterias Mamarias/diagnóstico por imagen , Adulto , Angiografía , Derivación Arteriovenosa Quirúrgica , Humanos , Síndrome de Leriche/cirugía , Ligadura , Masculino , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Injerto VascularRESUMEN
OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.
Asunto(s)
Neoplasias de la Mama/cirugía , Enfermedad de la Arteria Coronaria/cirugía , Anastomosis Interna Mamario-Coronaria/métodos , Mamoplastia , Microcirugia , Adulto , Anciano , Anciano de 80 o más Años , Mama/irrigación sanguínea , Neoplasias de la Mama/epidemiología , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Humanos , Incidencia , Anastomosis Interna Mamario-Coronaria/estadística & datos numéricos , Mamoplastia/estadística & datos numéricos , Arterias Mamarias/diagnóstico por imagen , Arterias Mamarias/patología , Arterias Mamarias/cirugía , Persona de Mediana Edad , Radiografía , Trasplante AutólogoRESUMEN
BACKGROUND: The internal thoracic (IT) vessels (otherwise known as the thoracica interna or internal mammary vessels) are widely used as recipient vessels in autologous breast reconstruction. Despite this, normal and pathological variations in IT artery architecture have been described, and these have the potential to complicate dissection and the selection of suitable vessels. METHODS: A clinical anatomical study of 240 IT arteries (120 patients) and review of the literature was undertaken. Participants comprised 120 female patients undergoing preoperative imaging of the IT artery prior to autologous breast reconstruction, 42 with computed tomographic angiography (CTA) and 78 with ultrasound. RESULTS: There was complete concordance between surgical and radiological findings. An IT artery was present in 100% of cases, with a duplicate IT artery in two cases (1% overall). The position of the IT artery was between two IT veins most frequently (71.5% of cases), and was lateral to the vein(s) least frequently (6%). There were large IT perforators from the first and second intercostal spaces in 87 and 91% of cases, respectively, with the incidence of such perforators reducing in the lower spaces. The literature highlighted a range of cadaveric and clinical cases in which there was absence of a patent IT artery, variant course or size, and variant relationship to the IT vein. CONCLUSION: A range of congenital, pathological and iatrogenic variants in IT artery anatomy have the potential to limit the use of the IT artery in autologous breast reconstruction. Preoperative imaging with ultrasound or CTA may provide a clear and accurate method of identifying these anatomical variations pre-operatively.