Outcomes after uterine artery embolization for pedunculated subserosal leiomyomas.

PURPOSE: To assess the safety and efficacy of uterine artery embolization (UAE) treatment of pedunculated subserosal leiomyomas. MATERIALS AND METHODS: A review of patients undergoing UAE in a 30-month period (July 2004 to December 2006) was performed. Cases in which a pedunculated subserosal tumor (volume>or=4 cm3) was embolized were analyzed. The preprocedural volumes of the pedunculated tumor and uterus and the diameter and vascularity of the tumor and stalk were recorded. Posttreatment sizes of the pedunculated leiomyoma, stalk, and uterus were recorded, as was the presence or absence of complication(s). RESULTS: A total of 240 patients underwent embolization. Pedunculated subserosal leiomyomas were treated in 16 women, with a technical success rate of 100%. Preprocedural mean tumor and uterine volumes were 372 cm3 and 789 cm3, respectively. The mean stalk diameter was 2.7 cm (range, 0.8-7.8 cm). All pedunculated leiomyomas exhibited enhancement on contrast agent-enhanced magnetic resonance (MR) imaging (n=13) or vascularity on Doppler ultrasonography (US; n=3). Stalk vascularity was noted on MR imaging in 13 patients and was not assessed in the remaining three, who underwent US imaging. Imaging follow-up (mean, 5.9 months after UAE) demonstrated mean tumor volume reduction of 39.3% (95% confidence interval [CI], 28.2%-50.5%) and mean uterine volume reduction of 37.6% (95% CI, 26%-49.3%). There were no cases of continued tumor perfusion and no major complications. There was one minor complication of prolonged hospital stay (36 hours) for pain control. CONCLUSION: UAE was successfully and safely performed for pedunculated subserosal leiomyomas, with a tumor volume reduction of 39% and no unique complications related to these lesions.

Clinical failure after uterine artery embolization: evaluation of patient and MR imaging characteristics.

PURPOSE: To investigate the patient and magnetic resonance (MR) imaging characteristics associated with clinical failure after uterine artery embolization (UAE). MATERIALS AND METHODS: Seventy-eight consecutive patients who underwent UAE were examined. Contrast-enhanced MR imaging was performed before and 4 months after the procedure, and clinical follow-up was performed at 15 months. Patients were divided into success and failure groups strictly on the basis of their clinical outcomes. Clinical follow-up included evaluation of fibroid symptoms and the need for further treatment after UAE. Findings at pre- and postprocedural MR imaging were compared, and data collected included changes in uterine and fibroid volumes, fibroid location, and fibroid perfusion. RESULTS: Fifty-eight patients were placed into the success group and 20 into the failure group. There were no differences between the baseline characteristics of the two groups. The reduction in uterine and dominant fibroid volumes was greater in the success group compared with the failure group; however, the difference was not statistically significant (success group: [295/845] 34.9% vs [80/282.5] 28.3%, respectively, P=.18; failure group: [317/733] 43.2% vs [114/337.6] 33.9%, P=.32). The reduction in total fibroid volume was greater in the success group than the failure group ([189.6/393.5] 48.2% vs [148.7/439.9] 33.8%, respectively; P=.02) despite the fact that the percentage of fibroids completely infarcted was similar between the two groups ([136/172] 79% vs [41/50] 82%, P=.77). Pedunculated subserosal fibroids were more common in the failure group than in the success group (P<.03) and did not reduce in volume as significantly (53.8% vs 14.7%, respectively; P=.02). CONCLUSIONS: In general, the reduction in total fibroid volume after embolization is smaller in patients with poor clinical improvement. In addition, these patients have a higher number of pedunculated subserosal fibroids, and these fibroids tend to reduce in volume to a lesser extent.

Performance of carotid stenting, vertebroplasty, and EVAR: how many are we doing and why are we not doing more? A survey by the Canadian Interventional Radiology Association.

OBJECTIVE: To determine the percentage of interventional radiologists who currently perform 3 interventional procedures: carotid stenting, vertebroplasty, and endovascular aneurysm repair (EVAR) in Canada, and impediments to their future performance by other interventional radiologists. METHODS: An anonymous online survey was emailed to all members of the Canadian Interventional Radiology Association (CIRA). The survey was open for a period of 2 months. RESULTS: A total of 75 survey responses were received (of an estimated 247). Carotid stenting, vertebroplasty, and EVAR were performed at 40%, 59%, and 46% of respondents' centres respectively. Wait times, from referral to consultation, and from consultation to procedure, were both typically between 2 to 4 weeks, longer for EVAR. Of respondents currently not performing these procedures, 26%, 28%, and 16% anticipated beginning to perform carotid stenting, vertebroplasty, and EVAR, respectively, in the proceeding year from time of survey. Of respondents who wished to perform the procedure, the greatest impediments were a lack of training, lack of a referral base, and lack of support from their radiology department and (or) colleagues. CONCLUSIONS: Although carotid stenting, vertebroplasty, and EVAR were being performed at about one-half of respondent's centres, and there will likely be greater adoption of the procedures in the near future, there remain substantial impediments. The greatest impediments to additional radiologists performing these procedures were a lack of training, lack of referral base, and lack of support from their radiology department and (or) colleagues. The former impediment suggested an unmet need for additional training courses.

Limitations influencing interventional radiology in Canada: results of a national survey by the Canadian Interventional Radiology Association (CIRA).

PURPOSE: To describe the current state and limitations to interventional radiology (IR) in Canada through a large, national survey of Canadian interventional radiologists. METHODS: An anonymous online survey was offered to members of the Canadian Interventional Radiology Association (CIRA). Only staff radiologists were invited to participate. RESULTS: Seventy-five (75) responses were received from a total of 247, giving a response rate of 30%. Respondents were split approximately equally between academic centers (47%) and community practice (53%), and the majority of interventional radiologists worked in hospitals with either 200-500 (49%) or 500-1,000 (39%) beds. Procedures listed by respondents as most commonly performed in their practice included PICC line insertion (83%), angiography and stenting (65%), and percutaneous biopsy (37%). Procedures listed as not currently performed but which interventional radiologists believed would benefit their patient population included radiofrequency ablation (36%), carotid stenting (34%), and aortic stenting (21%); the majority of respondents noted that a lack of support from referring services was the main reason for not performing these procedures (56%). Impediments to increasing scope and volume of practice in Canadian IR were most commonly related to room or equipment shortage (35%), radiologist shortage (33%), and a lack of funding or administrative support (28%). CONCLUSION: Interventional radiology in Canada is limited by a number of factors including funding, manpower, and referral support. A concerted effort should be undertaken by individual interventional radiologists and IR organizations to increase training capacity, funding, remuneration, and public exposure to IR in order to help advance the subspecialty.

Percutaneous sodium tetradecyl sulfate sclerotherapy for peripheral venous vascular malformations: a single-center experience.

PURPOSE: To evaluate the efficacy, safety, and long-term outcomes of percutaneous sodium tetradecyl sulfate (STS)sclerotherapy for peripheral venous vascular malformations (VVMs). MATERIALS AND METHODS: A retrospective review of a prospectively compiled database was performed to identify patients with a VVM who were referred from 1997 to 2004. Of the 132 patients identified, 78 underwent sclerotherapy. Six of the 78 patients were lost to follow-up. Of the remaining 72 patients (24 male and 48 female patients; mean age, 31.7 years; age range, 14-62 years), 42 (58%) had lower limb VVMs, 19 (26%) had upper limbVVMs, and nine (12%) had truncal and/or central VVMs. Two patients (2.8%) had multifocal lesions. Seven of the 72 patients (9.7%) had Klippel-Trénauney syndrome. Treatment response was assessed clinically and by means of lesion size measurement with magnetic resonance (MR) imaging. RESULTS: A total of 226 treatment sessions were performed (mean, 3.1 sessions per patient; range, 1-13 sessions). The mean follow-up was 41 months (range, 21-84 months). After treatment, 11 patients (15%) became asymptomatic, 20(28%) rated the response to therapy as good, 17 (24%) improved, 20 (28%) were unchanged, and four (5.6%) worsened.Thirty-five patients underwent MR imaging before and after treatment. The size of the VVM was seen to decrease in19 patients (54%), be unchanged in 11 (31%), and increase in five (14%). A reduction in lesion size at MR imaging did not necessarily correlate with a positive clinical response. Overall, patients with infiltrative lesions had a poorer outcome than did those with localized lesions. There were no major complications and seven minor complications(3.1% per session, 9.7% per patient). CONCLUSIONS: An improvement in symptoms was observed in 70% of the patients with VVMs treated with percutaneous STS. Although the treatment is safe, complete cure is unusual and multiple treatment sessions are almost always required.

Patency of endovascular treatment for central venous stenosis: is there a difference between dialysis fistulas and grafts?

PURPOSE: To determine if there is a difference in intervention patency for central venous stenosis (CVS) and occlusion between patients with autogenous hemodialysis fistulas and those with grafts. MATERIAL AND METHODS: A retrospective study was performed from March 1998 to September 2005 identifying all patients with autogenous fistulas and synthetic grafts who underwent percutaneous angioplasty and/or stent placement for CVS. This study cohort consisted of 38 patients (22 with fistulas and 16 with grafts). Age, sex, type of access, location and side of the access, location and side of the CVS, presence of diabetes, previous hemodialysis catheter placement, date and type of interventions, and outcomes were recorded. The patency of each intervention was estimated by using the Kaplan-Meier survival curves. Univariate and multivariate analysis of the variables were performed. RESULTS: Eighty-nine interventions were performed; 83 were angioplasties and six were stent placements. Previous catheter placement on the side of the CVS occurred in 29 of the 38 patients (76%). Technical and clinical success of the interventions were 93.3% and 94.4% respectively. The intervention or primary patency rates +/- standard errors at 3, 6, and 9 months in the fistula group were 88.5% +/- 4.8, 59.4% +/- 7.6, and 46% +/- 7.9, respectively. In the graft group, the rates were 78.1% +/- 7.3, 40.7% +/- 9, and 16% +/- 7.3, respectively. With multivariate analysis, intervention patency remained significantly longer for fistulas (P .014) and in patients who did not have a previous catheter (P .001). CONCLUSION: Longer intervention-free survival for CVS was observed in patients with autogenous fistulas compared with grafts and in patients who did not previously undergo hemodialysis catheter insertion.

The clinical interventional radiologist: results of a national survey by the Canadian Interventional Radiology Association.

OBJECTIVE: To determine the level of clinical responsibility interventional radiologists in Canada currently have within their practice and would like to have within their future practices. METHODS: An anonymous online survey was e-mailed to all members of the Canadian Interventional Radiology Association. The survey was open for a period of 2 months. RESULTS: A total of 75 surveys were received, of a possible 247, a response rate of 30.4%. Responses regarding general measures of clinical duties were collected. The current situation in Canada is mixed, in that while most (82%) respondents perform procedures that require an overnight admission, only 11% have a dedicated interventional radiology (IR) ward and 29% have admitting privileges. Most (73%) respondents stated that interventional radiologists in Canada should become more clinical. The most common reason cited for a lack of admitting privileges was a lack of time (44%), followed by a lack of hospital or administrative support (40%), "other" (20%), and inadequate remuneration (14%). CONCLUSIONS: Most respondents believe that interventional radiologists should become more clinically oriented. The most frequently noted obstacles to becoming more clinically oriented are reluctant administration, lack of time, and inadequate remuneration for clinical duties.

Uterine artery embolization--inpatient and outpatient therapy: a comparison of cost, safety, and patient satisfaction.

OBJECTIVES: To determine whether uterine artery embolization (UAE) can be safely performed as an outpatient procedure without increased complications and readmission rates or decreased patient satisfaction rates and to determine the Canadian cost difference between performing UAE as an outpatient, compared with inpatient, procedure. METHODS: We performed a retrospective chart review and patient survey of 2 groups of patients, 132 patients who underwent inpatient UAE and 20 patients who underwent outpatient UAE. Of these, 82 and 18, respectively, were successfully surveyed by telephone. Variables examined included presenting complaints, postprocedural symptoms, patient satisfaction, and readmission or complication rates. We also performed a detailed Canadian cost analysis comparing inpatient with outpatient UAE. RESULTS: We did not find any statistically significant difference between inpatient and outpatient UAE on any of the patient variables measured, including presenting complaints, postprocedural symptoms, patient satisfaction, and readmission or complication rates. We also found that outpatient UAE costs significantly less than inpatient UAE, primarily owing to decreased hospital overhead costs for overnight admission. In Ontario, inpatient UAE costs per patient totalled dollars 3216.22, whereas outpatient costs totalled dollars 2194.53--a saving of dollars 1021.69, which represents a 31.8% cost reduction. CONCLUSION: Given these results, we recommend that centres consider performing UAE as an outpatient procedure. A key enabling factor is the ability to have several hours of close nursing supervision of the patient postprocedure, prior to discharge.

Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroids.

Four patients with symptomatic uterine fibroids measuring less than 6 cm underwent laparoscopic ultrasound-guided radiofrequency ablation (RFA) using multiprobe-array electrodes. Follow-up of the treated fibroids was performed with gadolinium-enhanced magnetic resonance imaging (MRI) and patients' symptoms were assessed by telephone interviews. The procedure was initially technically successful in 3 of the 4 patients and MRI studies at 1 month demonstrated complete fibroid ablation. Symptom improvement, including a decrease in menstrual bleeding and pain, was achieved in 2 patients at 3 months. At 7 months, 1 of these 2 patients experienced symptom worsening which correlated with recurrent fibroid on MRI. The third, initially technically successfully treated patient did not experience any symptom relief after the procedure and was ultimately diagnosed with adenomyosis. Our preliminary results suggest that RFA is a technically feasible treatment for symptomatic uterine fibroids in appropriately selected patients.

Percutaneous management of chronic mesenteric ischemia: outcomes after intervention.

PURPOSE: To assess the efficacy and durability of percutaneous transluminal angioplasty (PTA)/stent placement for treatment of chronic mesenteric ischemia (CMI). MATERIALS AND METHODS: A retrospective review of patients treated from January 1986 to August 2003 was conducted. Twenty-nine patients (mean age, 62 years) were treated for clinical symptoms consistent with CMI. Clinical diagnosis was verified with angiographic assessment and PTA with or without stent placement was performed based on angiographic and/or pressure gradient findings. Outcomes were estimated with the Kaplan-Meier method. RESULTS: A total of 63 interventions were performed in 29 patients during the study period. Of these 63 interventions, 46 PTA and 17 stent implantation procedures were performed. Thirty-four interventions were performed for SMA stenosis/occlusion, 17 interventions for celiac artery stenosis/occlusion, and four interventions were performed on aorto-mesenteric graft stenoses. Technical success was 97%, and clinical success (defined as clinical resolution of symptoms) was 90% (26 of 29 patients). Mean duration of follow-up was 28.3 months. Primary patency for all interventions at 3, 6, and 12 months was 82.7% (95% CI: 68.7-96.7), 78.9% (66.7-91.1), and 70.1% (55.1-85.6), respectively. Primary assisted patency for all interventions at 3, 6, and 12 months was 87.9% (79.0-95.3), 87.9% (79.2-95.1), and 87.9% (77.3-98.3), respectively. An average of 1.9 interventions per patient was required. One major complication occurred (3.4%). There were three minor complications (10.3%). CONCLUSIONS: Percutaneous intervention for CMI is safe with durable early and midterm clinical success. However, repeated intervention is often required for improved primary assisted patency.

Current issues of interventional radiology in Canada: a national survey by the Canadian Interventional Radiology Association.

OBJECTIVE: To determine current issues facing the field of interventional radiology (IR) in Canada. METHODS: An anonymous online survey was emailed to all members of the Canadian Interventional Radiology Association. The survey was open for 1 month. RESULTS: A total of 83 survey responses were received (of an estimated possible 233). Responses regarding demographics, aspects of practice, research, and IR trainee education were collected. CONCLUSIONS: Several issues were identified as pertinent to Canadian interventional radiologists, including a current and future drought of interventional radiologists, a lack of women in the profession, inadequate protected research time for those in academic practice, a lack of protected clinical time, concern regarding turf issues with other specialties, division between interventional and diagnostic radiology, and the ideal profile of the future interventional radiologist. The field of interventional radiology (IR) continues to develop, expand, and mature at a rapid pace. As the field is still relatively young, several issues are bound to arise. It is important therefore to stay abreast of the current trends and opinions of practitioners within the field.

Pain after percutaneous liver biopsy for diffuse hepatic disease: a randomized trial comparing subcostal and intercostal approaches.

PURPOSE: To compare pain levels as measured by visual analog scale (VAS) and analgesic requirement between intercostal and anterior subcostal ultrasound (US)-guided biopsy. MATERIALS AND METHODS: Seventy consecutive patients were randomized to undergo biopsy via an intercostal (n = 33) or subcostal (n = 37) approach. The groups were matched with regard to baseline characteristics: mean age, 44 years; age range, 20-70 years; sex, 43 male and 27 female; and indications of hepatitis C in 69%, hepatitis B in 16%, and others in 15%. The VAS score was obtained immediately after biopsy and hourly for 4 hours until the patients were discharged. Analgesic requirements and postprocedural complications were documented. RESULTS: No significant difference in VAS scores was seen between the groups. At hours 0, 1, 2, 3, and 4, the VAS scores (on a scale of 100) in the intercostal and subcostal groups were 10.3 +/- 16.7 versus 11.8 +/- 16.0 (P = .70), 19.1 +/- 24.0 versus 13.9 +/- 16.2 (P = .30), 11.5 +/- 14.8 versus 11.8 +/- 15.1 (P = .93), 6.2 +/- 8.9 versus 7.5 +/- 11.5 (P = .63), and 5.4 +/- 8.2 versus 4.7 +/- 8.5 (P = .72), respectively. The average VAS was less than 10. In the intercostal biopsy group, 36.4% of patients required additional analgesia after biopsy, compared with 27.0% in the subcostal biopsy group (P = .64). One patient in the intercostal group refused to have future follow-up biopsy even if it was clinically indicated, compared with no such patients in the subcostal biopsy group. No differences in diagnostic samples or major complications were seen in either group. CONCLUSION: US-guided percutaneous liver biopsy performed with fentanyl and midazolam premedication is a well-tolerated procedure with minimal patient discomfort. The location of the biopsy does not influence the outcome of the procedure.

Echogenic ovarian foci without shadowing: are they caused by psammomatous calcifications?

PURPOSE: To determine and report the spectrum of ultrasonographic appearances of echogenic ovarian foci (EOF) without shadowing in otherwise normal ovaries and the histopathologic and physical characteristics of these foci. MATERIALS AND METHODS: The appearances of foci on transvaginal pelvic sonograms obtained in 189 patients with EOF were prospectively analyzed. The foci were classified according to bilaterality, size, number (<5, 5-10, or >10), and location (peripheral, central, or diffuse). At histopathologic analysis, resected normal ovaries, seven with and 10 without echogenic foci, in a water bath were scanned. The foci were then localized for histopathologic correlation. To assess the physical properties of the foci, tissue-mimicking water- and glycerol-based phantoms, with voids of different diameters, in a water bath were scanned with 8- and 70-MHz transducers. RESULTS: At appearance analysis, EOF (mean diameter, 1.8 mm +/- 0.6 [SD]) were detected unilaterally in 103 (54.5%) of 189 patients. EOF were distributed peripherally in 183 (66.5%), centrally in 15 (5.5%), and diffusely in 77 (28.0%) of 275 ovaries. There were fewer than five foci in 123 (44.7%), five to 10 foci in 91 (33.1%), and more than 10 foci in 61 (22.2%) of 275 ovaries. At histopathologic analysis of the seven ovaries with EOF, the foci had tiny cysts with no evidence of calcifications. A single cyst cluster was identified in two of 10 ovaries that did not have echogenic foci. At physical property analysis, single echogenic foci were associated with specular reflection from the walls of unresolved cysts that were comparable in size to the ultrasound wavelength (about 0.50 mm). CONCLUSION: EOF without shadowing are caused by a specular reflection from the walls of tiny unresolved benign cysts rather than by psammomatous calcifications.