Utero-ovarian anastomoses and their influence on uterine fibroid embolization.

PURPOSE: To correlate clinical outcomes after uterine artery embolization (UAE) performed to treat uterine fibroids with the presence of varying types of utero-ovarian anastomoses (UOA). MATERIALS AND METHODS: A retrospective analysis was performed of all uterine angiograms from 202 patients (mean age 42 y, range 28-54 y) who underwent UAE because of heavy menstrual bleeding, dysmenorrhea, or anemia or a combination of these symptoms. UOA were classified as absent or present, unilateral or bilateral. The effects of UOA on long-term outcomes (clinical endpoints such as control of bleeding and pain) and complications (amenorrhea) were assessed statistically using Kaplan-Meier curves and χ(2) and log-rank tests. RESULTS: Of the UOA in 104 women, 38 anastomoses were bilateral, and 66 were unilateral. Type III was the most common type of anastomosis (66 cases) followed by type Ia (22 cases) and type Ib (18 cases); there were no type II anastomoses. Amenorrhea was reported in 27 (14%) women at 5-year follow-up after UAE (only 3% in women < 45 y old). There were 10 cases of clinical failure with a median follow-up of > 4 years. Bilateral or unilateral presence of UOA had no statistically significant effect on outcomes or on complications. CONCLUSIONS: Recurrence rates, clinical failure, and amenorrhea after UAE do not seem to be influenced by the presence or absence of UOA. However, further studies are needed to confirm these findings.

Treating epiphora in adults with the Wilhelm plastic nasolacrimal stent: mid-term results of a prospective study.

The objective of the present study was to evaluate, in a prospective, single-center study, the effectiveness of the Wilhelm-type stent used in interventional radiology for the management of epiphora. Patients (n = 104; mean age 64 [range 25­88]; 33 male and 71 female) with severe epiphora had the stents inserted (135 stents in 115 eyes) to treat obstruction of the nasolacrimal system. The etiology of the obstruction was idiopathic in 83 cases, chronic dacryocystitis in 31, cases and postsurgical status in 1 case. The overall technical success rate of stent placement was near 94%. Resolution of epiphora was complete in 105 cases and partial in 3 cases. During a mean 13-month follow-up (range 1 week to 28 months), the median duration of primary patency was 11 months, and the percentage of patency at 6 months was 60.8%, at 1 year was 39.6%, and at 2 years was 25%. Stents malfunctioned in 54 cases, and all were easily withdrawn except in 1 case. Of these 27 cases, patency recovered spontaneously in 9 and by way of a second stent in 18. Secondary patency was 50%. Factors presdisposing to lower primary patency are inflammatory etiology and location of the obstruction. The benefit of stent deployment is clear with respect to the resolution of epiphora in candidate patients for percutaneous treatment. Technical and/or design improvements would be welcomed.

Randomized comparison of nasolacrimal cryoplasty versus plastic lacrimal stenting in the management of epiphora in adults.

PURPOSE: To evaluate the efficacy of plastic polyurethane stents compared with nasolacrimal cryoplasty in the management of epiphora in adults. MATERIALS AND METHODS: Patients (N = 37; mean age, 64 years; range, 34-86 y; six men, 31 women) with severe epiphora with partial/complete obstruction of the nasolacrimal system were randomized to have a plastic stent inserted (n = 19) or to undergo balloon dilation cryoplasty (n = 18). Both procedures were conducted on an outpatient basis. Patency was assessed with Kaplan-Meier curves. RESULTS: Initial technical success rate and immediate resolution of epiphora was complete in all cases. At 6 months of follow-up, outcomes were already significantly different between the treatment groups and hence the study was discontinued. Plastic stent placement achieved a primary patency rate of 59.6% at 6 months, compared with 12.4% in the cryoplasty group (P < .0004). Multivariate analysis indicated that other measured variables (sex, age, etiology, previous treatment, and the interventional radiologist's expertise) had no significant effect on the outcomes (P > .05). CONCLUSIONS: Initial success was good in both treatment groups, with nasolacrimal plastic stent placement achieving a level of primary patency superior to the cryoplasty procedure for the relief of epiphora on short-term follow-up. However, long-term outcome evaluation is needed before stent placement can be recommended as an alternative to more established surgical procedures.

Nasolacrimal stenting: toward improving outcomes with a simple modification of the song stent.

The purpose of this study was to evaluate, in a prospective, single-center study, the effectiveness of Song's polyurethane stents, modified "in-house," in the percutaneous management of epiphora. Patients (n = 170; age range 18-83, mean = 64; 50 male, 120 female) with severe epiphora had the modified stents inserted (183 eyes/195 stents) to treat unilateral/bilateral and complete/partial obstruction of the nasolacrimal system. The etiology of the obstruction was idiopathic in 119 cases (61%) and chronic dacryocystitis in 76 (39%). The set designed by Song was used in all patients but modified by us such that the extreme end is cone-shaped. The original technique was slightly modified by us and the procedure was conducted on an outpatient basis. The initial technical success rate of stent placement was 97%. Resolution of epiphora was complete in 180 eyes and partial in 3. On follow-up (mean = 18 months; range: 2 days to 24 months), 165 of 195 stents (85%) remained patent. Primary patency rates at follow-up were 86%, 84%, 84%, and 79% in the first 6 months, second and third 6 months, and the present (24 months), respectively. Stents became obstructed in 30 patients, but all but 2 were easily withdrawn and 20 of these patients remained asymptomatic for a mean of 14 months (secondary patency of 67%). Following stent removal, the withdrawn stent was replaced with a new stent in the same intervention on 14 occasions. In another six cases, patency was re-established without the need of a second stent. The procedure is simple and safe, both in stent insertion as well as in mechanical de-blocking and withdrawal when occluded. Success was >80 % in the short term (1-year follow-up). Stenting failure does not preclude other treatment because with the modification that we had introduced, the extreme end of the stent becomes more accessible to mechanical de-blocking, withdrawal, and relocation. The levels of primary and secondary patencies are promising and warrant more extensive investigation.

Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi.

OBJECTIVE: Our study describes the percutaneous expulsion of bile duct calculi into the duodenum by dilating the papilla with a balloon catheter. SUBJECTS AND METHODS. Patients (n = 212; 101 men and 111 women; mean age, 73 years; range, 31-95 years) had their calculi (single, 131; multiple, 81) percutaneously expelled into the duodenum in 73 patients via an indwelling T tube, and in 139 via transhepatic or transcystic duct route. Stone expulsion was facilitated with an occlusion balloon after balloon sphincteroplasty and with prior mechanical fragmentation in only 37 patients. After the expulsion of the calculi into the duodenum, drainage of the main bile duct to the exterior was maintained for 2-8 days. RESULTS: Technical success was initially 90.4%, increasing to 93% at the second attempt. There were 13 failures due to the large size of the calculi in nine patients, excessive tortuosity of the T tube (Kher tube) in one, and breaches of the established protocol in two. Residual lithiasis was resolved in 98.6% of cases, decreasing to 92% in the group of native, or nonresidual, lithiasis. There were 10 major complications (hemobilia) with three cases of poor clinical outcome: hepatic necrosis, multiorgan failure, or death. CONCLUSION: Percutaneous anterograde evacuation of bile duct stones with dilatation of the papilla using an angioplasty catheter and assisted with an occlusion balloon to expel the calculi is a cost-effective, nontraumatic, and safe procedure that retains the anatomic and functional integrity of the sphincter. It is a viable alternative procedure in the treatment of bile duct lithiasis.