[Conservative placenta percreta management using uterine arterial embolization procedure: A series of 12 cases]. / Prise en charge conservatrice du placenta percreta vésical avec embolisation des artères utérines : à partir d'une série continue de 12 cas.

We report a retrospective series of 12 placentas percreta with bladder invasion and for which an expected initially multidisciplinary conservative surgical treatment associated with uterine artery embolization was programmed. Conservative surgical treatment was only performed in 7 women. Radical surgical treatment was necessary during the caesarean section and complicated by massive hemorrhage in three women and secondary in two other women for infectious diseases. Radical surgical treatment was associated with partial cystectomy complicated with urinary disorder sequelae in three women. Maternal morbidity of the placenta percreta bladder remains high despite the establishment of a multidisciplinary care protocol.

Imaging of giant cerebral aneurysms.

The aim of this study was to review the different imaging techniques for analysing giant intracranial aneurysms (digital subtraction angiography [DSA], magnetic resonance imaging [MRI], computed tomography [CT]) imaging and explain their respective contribution to the understanding of the characteristics of these complex aneurysms. Giant aneurysms have a complex pathology with multiple stages of evolution and consequences. Therefore, complex imaging is mandatory to enhance the understanding of these parameters and to plan an often complicated treatment strategy. DSA remains the gold standard for analysing aneurysms, but non-invasive sectional imaging (CT, MRI) also provides essential information in the specific case of giant aneurysms.

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage.

OBJECTIVES: To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine-sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia. DESIGN: Retrospective study. SETTING: University-affiliated tertiary referral centre. POPULATION: All consecutive women who had an embolisation with or without uterine-sparing surgery (vessel ligation and/or uterine compression) for postpartum haemorrhage between 1994 and 2007 were included. METHODS: Data were retrieved from medical files and telephone interviews. MAIN OUTCOME MEASURE(S): Fertility and pregnancy outcomes, synechia. RESULTS: Data were available for 68 of the 85 women (80%) included in the study. Among the 15 women who complained of amenorrhoea or decreased flow of menstruation, synechia was found in all those who decided to undergo an ambulatory hysteroscopy (n = 8). Seventeen women had 26 pregnancies with 19 term deliveries, one ectopic pregnancy, two abortions and four miscarriages. The clinical courses of the 19 complete gestations were uneventful, but postpartum haemorrhage recurred in six women (31.6%) (caused by placenta accreta in two women). Fertility and pregnancy outcomes did not differ between women who had undergone embolisation versus both embolisation and a uterine-sparing surgical procedure. The occurrence of synechia was significantly associated with a higher rate of placenta accreta/percreta (P < 0.001) and postpartum fever above 38.5 degrees C (P = 0.04). CONCLUSIONS: Embolisation, whether or not associated with a uterine-sparing surgical procedure, for postpartum haemorrhage does not appear to compromise a woman's subsequent fertility and obstetric outcome. Nevertheless, these women should be considered at high risk for postpartum haemorrhage during future deliveries.

[Buttock necrosis after subtotal hysterectomy, bilateral internal iliac arteries ligature and pelvic embolization for control of severe post-partum haemorrhage]. / Un cas de nécrose de fesse survenant après hystérectomie subtotale, ligature bilatérale des artères iliaques internes et embolisation pelvienne pour une hémorragie grave du post-partum.

Post-partum haemorrhage remains a major cause of maternal mortality. Surgical management may be needed in patients with hemodynamic instability. Arterial embolization may be needed in case of persisting haemorrhage despite initial surgical management. We report a case of buttock necrosis occurring after pelvic embolization to control refractory post-partum haemorrhage and failed subtotal hysterectomy with bilateral internal iliac arteries ligation. To the best of our knowledge, this is the first case of buttock necrosis complicating a severe post-partum haemorrhage reported in the literature.

Usefulness of multislice computerized tomography angiography in preoperative diagnosis of ruptured cerebral aneurysms.

OBJECTIVE: Non-invasive imaging methods have become primordial in subarachnoid hemorrhage. The aim of our study was to evaluate the sensitivity and specificity of multislice computed tomographic angiography (MSCTA) for the diagnosis of cerebral aneurysm. METHODS: The 28 included consecutive patients with SAH underwent both MSCTA and digital subtraction angiography (DSA). The MSCTA studies were interpreted by two independent readers (A and B) for the presence, the location and size of the aneurysm comparatively to the DSA as reference examination. RESULTS: In 20 patients, 38 aneurysms were diagnosed and in eight no aneurysm was found. Per patient basis, the diagnostic sensitivity and specificity were excellent. Per aneurysm basis, the diagnostic sensitivity and specificity of MSCTA were, respectively, 97.4 and 100% for reader A, 100 and 100% for reader B. For aneurysms less than 3mm, sensitivity was 100% for both readers. Interobserver agreement was excellent for the detection of aneurysm (kappa=0.98, 95% CI [0.96-1]). Intertechnique and interobserver agreements were excellent for the measurement of aneurysms (slope=0.86, r=0.91 p=3.1x10(-7) and slope=1.04, r=0.99, p<10(-6), respectively). CONCLUSION: MSCTA was an accurate and reproducible non-invasive imaging technique for preoperative diagnosis of ruptured cerebral aneurysm. The MSCTA may be proposed in first intention after the diagnosis of SAH was established, with special care regarding injection procedure and a strict reading method using native images and thin MPR.

[Spontaneous supratentorial cerebral hemorrhage: role of surgical treatment]. / Hémorragie cérébrale supratentorielle spontanée: quelle place pour un traitement chirurgical?

Until very recently, no specific therapies have been demonstrated to improve outcome after spontaneous intracerebral haemorrhage (ICH). The STICH (surgical treatment for intracerebral haemorrhage) study showed no overall benefit from early surgery when compared with initial conservative treatment. In contrast, the stereotactic aspiration technique can be safely performed and in a uniform manner. Despite the reduction of ICH volume, no improvement in mortality and functional result was obtained. Endoscopy is a new therapeutic option for ICH with good results for hematoma removal. Based on these feasibility studies, a randomized control trial regarding this procedure would be required to assess the efficacy of this procedure. Due to the lack of benefit observed in the recent STICH trial, emergency surgical evacuation should be reserved for patients with large lobar haemorrhage, mass effect and rapidly deteriorating clinical condition.

[Late post-conization hemorrhage and false aneurysm of the uterine pedicle]. / Hémorragie retardée post-conisation et faux anévrisme du pédicule utérin.

We report a case of delayed post-conization hemorrhage induced by the rupture of a uterine artery false aneurysm. Cold knife conization of the cervix was the main cause of the false aneurysm. To our knowledge, this is the first case reported. Angiography enabled the diagnosis and the treatment by embolization of the lesion. A less aggressive technique than a scalpel, perhaps with a diathermic loop, could help to prevent this type of complication.

[Unruptured intracranial aneurysm: possible therapeutic strategies?]. / Anévrismes intracrâniens non rompus: que proposer?

Intracranial unruptured aneurysm (ICUA) has become a common condition for patient consultation. The mortality rate after fissuration is estimated to be between 52% and 85.7%. The final therapeutic decision results from a balance between the risk of rupture and risks related to the aneurysmal exclusion. Analysis of the risk of rupture risk enables a classification of risk factors. Depending on the circumstances of diagnosis, we considered the ICUA at high risk of rupture for incidental ICUA larger than 7 mm and in the event of associated aneurysms. Classifying by morphologic features, high-risk ICUA were located in the vertebrobasilar system (RR: 4.4; 95%CI: 2.7-6.8), those with a size between 7 and 12 mm (RR: 3.3; 95%CO: 1.3-8.2), larger than 12 mm (RR: 17; 95%CI: 8-36.1), those that were multilobular or a larger size and those ones with a index P/L superior to 3.4 (risk x20). Familial ICUA would expose to a major rupture risk (2 to 7 times sporadic ICUA). Some systemic factors were related to ICUA rupture: arterial hypertension (RR: 1.46; 95%CI: 1.01-2.11) and smoking addiction (RR: 3.04; 95%CI: 1.21-7.66). After microsurgical exclusion, the morbidity and mortality rates were 10% and 2% respectively. Some microsurgical morbidity factors were identified: age (32%>65 years), size (14%>15 mm), vertebrobasilar location and temporary occlusion. The rupture incidence after microsurgical exclusion was estimated 0.26%/year. After endovascular exclusion, the morbidity and mortality rates were 8% and 1% respectively. The complete exclusion rate varied between 47% and 67%. The rupture risk was estimated at 0.9%/year. Treatment recommendations were classified into 3 categories.

Diagnosis of spinal dural arteriovenous fistula with multidetector row computed tomography: a case report.

Spinal dural arteriovenous fistulas are a rare cause of myelopathy. Nonspecific symptoms may delay the diagnosis. Magnetic resonance imaging and spinal angiography are routinely used to establish the diagnosis. In our case abnormalities on magnetic resonance imaging only suggested spinal dural arteriovenous fistulas. Multidetector row computed tomography (MRCT) led to the diagnosis which was confirmed by angiography.

[Intractable postpartum haemorrhages: where is the place of vascular ligations, emergency peripartum hysterectomy or arterial embolization?]. / Les hémorragies graves de la délivrance: doit-on lier, hystérectomiser ou emboliser?

OBJECTIVE: Update of knowledge on the various methods of management of intractable postpartum haemorrhage. METHOD: PubMed, MEDLINE were the electronic sources, in English and French languages, used for data retrieval. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, we dispose of angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method practicable by simple catheterization under local anesthesia. Vascular ligations of the uterine vessels or internal iliac arteries require mostly laparotomy. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience. RESULTS: For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In this case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta. CONCLUSION: The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be done, if there is no maternal haemodynamic disorder nor interventional vascular radiology unit nearby. During caesarean section, progressive uterine artery ligation can be done adapted to the bleeding cause. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum then should remain the choice procedure.

[Ruptured anterior communicating artery aneurysm. Therapeutic options in 119 consecutive cases]. / Anevrismes rompus de l'artère communicante antérieure. Choix thérapeutique à propos d'une série consécutive de 119 cas.

BACKGROUND AND PURPOSE: The respective roles of endovascular and surgical treatment must be clearly defined in the management of ruptured anterior communicating artery (AcoA) aneurysm. The aim of our study was to report our results, using the aneurysm direction as the main morphological argument to choose between microsurgery and endovascular embolization. Morbidity and mortality, causes of unfavorable outcome and morphological results were also assessed. PATIENTS AND METHODS: Our prospective study included 119 patients: 89 treated by microsurgery and 30 undergoing embolization with Guglielmi Detachable Coils (GDC). When the aneurysm had an anterior direction (fundus of the aneurysm in front of the pericallosal arteries), we attempted microsurgery. If the fundus of the aneurysm was behind the pericallosal arteries, we selected the most adapted procedure after discussion with the neurovascular team, taking into account the physiological status, treatment risk and neck size. Preoperative status of the patients was assessed according to the Hunt and Hess (HH) classification. Cerebral CT-scan and angiograms were routinely performed after treatment to determine causes of unfavorable outcome (GOS>1) and the morphological results. RESULT: Overall clinical outcome was excellent (GOS1) for 63.0% of patients, good (GOS2) for 10.1%, fair (GOS3) for 13.4%, poor (GOS4) for 2.5%. The mortality rate was 10.9%. Among the 82 patients in good preoperative grade (HHIII), 8 (21.6%) achieved an excellent outcome. However permanent morbidity or death occurred in 15 patients (78.4%). Permanent disability and death were related to initial subarachnoid hemorrhage and were observed 21.3% of patients in the microsurgical group and 30.0% in the endovascular group [Fisher's Exact Test; p=0.33]. Procedure-related permanent disability and death rates were 9.0% for the microsurgical group and 23.3% for the endovascular group (p=0.06) respectively. In the microsurgical group, the only morphologic characteristic which significantly correlated with the occurrence of vessel occlusion was the fundus direction (p=0.03). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (p=0.04). CONCLUSION: In our experience, the direction of the aneurysm was the main morphological criterion in choosing between microsurgery or endovascular procedure for the treatment of AcoA aneurysm. We propose that microsurgical clipping should be preferred for AcoA aneurysms with anterior direction, and depending on morphological criteria, endovascular packing for those with posterior direction.

Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage.

BACKGROUND: The long-term effects of uterine artery embolization for the control of postpartum haemorrhage on menses, fertility and future pregnancy evolution have not been assessed. METHODS: Between November 1993 and July 1999, 31 women with obstetric haemorrhage underwent arterial embolization. Four patients underwent a hysterectomy. Gynaecological information on 25 of the 27 patients who did not undergo hysterectomy was obtained by interview. RESULTS: All women had a return of normal menses. Nine of the 25 patients desired subsequent pregnancy and five patients became pregnant with normal delay of conception. Moreover, two other patients who did not plan another pregnancy became pregnant. A total of 10 pregnancies was studied, four ended during the first trimester. For the six others, the maternal evolution of the pregnancy was uneventful until term. No case of pre-eclampsia was observed. The ultrasonographic examinations revealed normal fetal growth and umbilical and uterine Doppler studies showed no anomaly. No repetition of obstetric haemorrhage was observed. All full-term, newborns were healthy, weighing from 3220 to 4100 g. CONCLUSION: Our results suggest that women who undergo arterial embolization for obstetric haemorrhage should expect to have a return of normal menses with preservation of future fertility and successful uneventful pregnancies.

[Renal arteriovenous fistula associated with fibromuscular dysplasia of the renal arteries]. / Fistule artérioveineuse rénale associée a une dysplasie fibromusculaire des artères rénales.

Three to 5% of hypertensive diseases have a renovascular origin. Atherosclerosis and fibromuscular dysplasia are the two major causes of renovascular hypertension. Association of renal arteriovenous fistula and fibromuscular dysplasia is uncommon. The authors propose to illustrate the usefulness of Doppler ultrasonography and digital subtraction angiography in the diagnostic and therapeutic management of a renal arteriovenous fistula associated with fibromuscular dysplasia discovered after severe preeclampsia in a 30 year-old woman.

Abnormal placentation and selective embolization of the uterine arteries.

OBJECTIVE: Abnormal placentation accounts for more than 50% of uterine artery embolization failure. The authors report their experience in this situation. STUDY DESIGN: Seven women presented with abnormal placentation. Uterine artery embolization was carried out in emergency or prophylactic control of postpartum bleeding. RESULTS: In five patients, control of postpartum hemorrhage was obtained without hysterectomy. In two cases with no placental removal and prophylactic procedures, hysterectomy and blood transfusion were not necessary. The manual removal of the placenta was achieved secondarily, respectively on the 25th and the 12th day. CONCLUSIONS: The success rate of uterine artery embolization for postpartum bleeding appears to be lower with abnormal placentation. In none of the cases with the placenta present was it possible to leave the residual placenta in place. However, embolization may permit a safe waiting period and spontaneous migration of the placenta. When the diagnosis is made before delivery, prophylactic uterine artery embolization without placental removal should be considered to reduce blood transfusion and preserve fertility.

False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization.

We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.

[Limits to arterial embolization treatment of severe postpartum hemorrhage]. / Facteurs d'échec de l'embolisation artérielle dans le traitement des hémorragies graves du post-partum.

OBJECTIVE: To assess the limits of arterial embolization in the management of serious postpartum haemorrhage (PPH). STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: We examined the cases of 29 patients admitted to intensive care units of Rouen University Hospital for PPH between January 1994 and August 1999. Demographic, obstetrical and biological data, the required treatment and eventual side effects were collected and analysed using the appropriate parametric and non parametric tests. RESULTS: Arterial embolization was carried out on 15 patients (52%) with a success rate of 73%. Of the 14 other patients, 11 underwent conservative or radical surgery without further complications, three received medical treatment. No maternal death occurred; however, one patient transferred from a local hospital and already presenting haemodynamic instability suffered cardiac arrest before embolization. Arterial embolization was unsuccessful in four cases, two of which were cases of placenta accreta. These patients were older (p < 0.05) and all had a past history of curettage and/or caesarean section for preceding deliveries (p < 0.01). CONCLUSIONS: Emergency arterial embolization is a valuable therapy in case of PPH but can only be carried out in specialised units. Obstetrical antecedents would appear to constitute a major risk factor and transfer increases the morbidity rate.

Traumatic subclavian artery pseudoaneurysm: periprocedural salvage of failed stent-graft exclusion using coil embolization.

PURPOSE: To report the exclusion of a subclavian pseudoaneurysm by a combination of covered stent implantation and coil embolization. CASE REPORT: A 30-year-old man presented with a posttraumatic pseudoaneurysm of the left subclavian artery. A covered Jostent was inserted via a percutaneous femoral approach and deployed in the injured subclavian artery. Because of tapering of the artery proximally, apposition of the covered stent to the arterial wall was insufficient, leading to persistent filling of the pseudoaneurysm. Exclusion of the pseudoaneurysm was achieved by coil embolization through a gap between the stent-graft and the arterial wall. CONCLUSIONS: This report illustrates that successful endovascular treatment of a left subclavian pseudoaneurysm may require a combination of catheter-based techniques.

Arterial erosions in acute pancreatitis.

Acute pancreatitis was observed in 492 patients. Fourteen (2.8%) developed an arterial erosion revealed by a haemorrhage either in the digestive lumen, in the peritoneum or via previously placed drainage. The eroded artery was the splenic artery in six patients, a pancreatico-duodenal artery in five patients. An initial haemostasis was attempted by: a) embolization in four patients: one died; the three others had bleeding recurrence. b) splenocorporeal pancreatectomy in four patients, three had bleeding recurrence. c) arterial ligature in four patients: three had bleeding recurrence. Secondary haemostatic procedures were performed in ten patients but a durable haemostasis was achieved in only five patients: two had a pancreatic resection and three were treated by a redo-binding. It is noteworthy that durable haemostasis could not be obtained neither by embolization nor by ligature in necrotic tissues. This could explain the difference in the results of arterial erosion treatments in chronic and in acute pancreatitis. Therefore, it is suggested that haemostatic procedures should be performed away from necrotic tissues, or eventually done after their removal.