The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation.

PURPOSE: The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE. MATERIALS AND METHODS: Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test. RESULTS: Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001). CONCLUSION: Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Treatment of stomal variceal hemorrhage with TIPS: case report and review of the literature.

We report a case in which recurrent hemorrhage from stomal varices was successfully treated by placement of a TIPS in a patient with prior colectomy for inflammatory bowel disease. Although several treatment options have been reported for this entity we believe that TIPS offers minimally invasive and definitive treatment.

The impact of uterine fibroid embolization on resumption of menses and ovarian function.

PURPOSE: To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function. METHODS: The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test. RESULTS: Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses. CONCLUSION: The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.

Superior vena cava syndrome. Experience with endovascular stents and surgical therapy.

Superior vena cava (SVC) syndrome is a serious complication of benign and malignant diseases. Benign causes may be increasing because of the increased use of central venous cannulation. Modern surgical therapy is durable with a few complications. Traditional treatment for SVC obstruction from malignant causes has consisted of anticoagulation, radiation, chemotherapy, and occasionally surgery. Endovascular techniques present a new treatment option for these patients, and uses a combination of thrombolysis, angioplasty, and intravascular stents. Short-term results are excellent with relatively rapid patient recovery. Further research is needed to elucidate the long-term results of endovascular treatment and to find its role in benign and malignant disease.

Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients.

PURPOSE: To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance. MATERIALS AND METHODS: With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test. RESULTS: During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001). CONCLUSION: There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

Phase II trial of chemoembolization for the treatment of metastatic colorectal carcinoma to the liver and review of the literature.

BACKGROUND: Hepatic artery chemoembolization represents an alternative treatment for patients whose neoplastic lesions are not amenable or have become refractory to other treatment modalities. This project was designed to test the feasibility of regional chemoembolization for patients with colorectal carcinoma metastasis to the liver who had experienced failure with one or more systemic treatments. METHODS: Thirty patients who met the study entry criteria underwent one to three hepatic artery chemoembolizations. The chemoembolization regimen consisted of an injection of a bovine collagen material with cisplatin (10 mg/mL), doxorubicin (3 mg/mL), and mitomycin C (3 mg/mL). Repeat treatments were performed at 6- to 8-week intervals. RESULTS: Radiologic responses, as measured by a decrease in lesion density of at least 75% of the lesion or a 25% decrease in the size of the lesion, occurred in 63% of the cases. A decrease of at least 25% of the baseline carcinoembryonic antigen level occurred in 95% of the cases. All responses were transient. Median survival for all 30 patients was 8.6 months after the initiation of chemoembolization and 29 months after the initial diagnosis of metastasis to the liver. Common toxicities included a "postembolization syndrome," which consisted of fever > 101 degrees F (83%), pain in the right upper quadrant (100%), nausea, and vomiting. Lethargy was a common occurrence (in 60+% of cases) and lasted up to 6 weeks. Hematologic toxicities included leukocytosis, anemia, and thrombocytopenia. CONCLUSIONS: Chemoembolization is a feasible treatment modality for patients with colorectal carcinoma metastasis to the liver who have experienced failure with other systemic treatments. It results in high response rates with transient mild-to-moderate toxicity. Responses are measured in months, however, and all patients have eventual progression of disease. Patients who are able to undergo three or more chemoembolization procedures may receive the most clinical benefit.

Helical computed tomography of the normal thoracic outlet.

PURPOSE: This study was performed to determine the detailed anatomy of the thoracic outlet in normal subjects using helical computed tomography (CT), with particular attention to vascular compression with arm movement. METHODS: Ten volunteers underwent detailed clinical evaluation and helical CT scanning of the upper thorax and neck with the arm in a neutral position and with the arm abducted 90 degrees or greater and externally rotated. Anterior scalene-clavicle distance (SC), costoclavicular distance (CC), and vessel diameters were measured with electronic calipers in each position. Comparisons were made with Student's t test. RESULTS: With abduction the SC decreased from 18.4 +/- 3.9 mm to 5.2 +/- 2.4 mm (p < 0.001), and the CC decreased from 12.6 +/- 2.7 mm to 6.3 +/- 3.3 mm (p = 0.005). At these same anatomic planes, the vein diameter decreased from 11.0 +/- 1.6 mm at the neutral position to 5.1 +/- 1.5 mm (p < 0.001) and from 16.1 +/- 3.0 mm to 7.4 +/- 2.6 mm with the arm abducted (p < 0.001). The artery diameter changed from 6.6 +/- 0.8 mm to 6.2 +/- 0.5 mm (p = 0.08) and from 7.2 +/- 0.8 mm to 6.0 +/- 0.5 mm (p = 0.001) with arm movement. CONCLUSIONS: Both the distances between the anterior scalene muscle and the clavicle and between the clavicle and the first rib are significantly reduced with abduction of the upper extremity. Venous compression is universal at both the SC and CC spaces in normal subjects with this maneuver. Arterial narrowing occurs less frequently and appears to be minor. Minor changes in these thoracic outlet dimensions (SC/CC) may produce venous compression without movement.

Treatment of venous malformations by direct injection with ethanol.

PURPOSE: Venous malformations (VMs) may be discrete or extensive, and larger lesions may be difficult to remove with surgery. Incompletely removed lesions have a tendency to recur. We report our experience with ethanol ablation of VMs. METHODS: All 12 patients (seven women; mean age, 37 years) were evaluated with magnetic resonance imaging before treatment. A total of 19 prior surgical excisions had been performed for seven of the patients. Symptoms were present in all 12 patients and included bleeding, pain, swelling, and limitation of exercise. The VMs were present in the lower extremities of seven patients, in the upper extremities of three patients, and in the flank and buttocks in two patients. RESULTS: The 12 patients have undergone 30 injection procedures, with six patients requiring one, three patients requiring two, two patients requiring three, and one patient having undergone 12 treatments. General anesthesia was used in 11 patients. Blood loss was minimal for all procedures, and 28 of the 30 procedures were technically successful. Skin ulceration was seen in approximately half of the treated VMs, all of which healed with local wound care. Focal VMs were injected in six patients and resolved with a single treatment in five patients. Patients were free of symptoms at a mean follow-up of 10 months. Extensive VMs were injected for discrete, symptomatic areas in five patients. These lesions all regressed and were asymptomatic at a mean follow-up of 23 months in all but one patient. However, these lesions required multiple treatments as additional areas became problematic. CONCLUSIONS: Ethanol sclerosis is a well-tolerated, safe, and effective adjunct to the management of VMs. Advantages of ethanol injection include the ability to treat a very localized area without an incision. Conversely, extensive lesions may be palliated as symptoms occur.

Symptomatic hemangiomas and venous malformations in infants, children, and young adults: treatment with percutaneous injection of sodium tetradecyl sulfate.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of percutaneous sclerosis therapy using sodium tetradecyl sulfate for treatment of symptomatic hemangiomas and venous malformations in infants, children, and young adults. MATERIALS AND METHODS: Fifty-two sclerosis procedures were performed in 21 patients who were 13 months to 24 years old. Six of these patients had hemangiomas, and the remaining 15 patients had venous malformations. Sodium tetradecyl sulfate was injected solely percutaneously in 49 procedures, by both percutaneous and arterial routes in two procedures, and intraarterially only in one procedure. Thirteen patients had sclerosis therapy alone, and eight patients had sclerosis therapy followed by surgery within 48 hr. RESULTS: Sclerosis therapy alone or sclerosis therapy followed by surgery was judged beneficial in 18 (86%) of 21 patients, including five of the six patients who had hemangiomas and 13 of the 15 patients who had venous malformations. Two patients had an equivocal response to the therapy, and one patient had no apparent benefit. Three of the 21 patients had minor complications (skin ulcers) but no long-term sequelae. CONCLUSION: Percutaneous injection of sodium tetradecyl sulfate, either alone or before surgery, is a safe and effective method of managing symptomatic hemangiomas and venous malformations.

Current management of visceral artery aneurysms.

BACKGROUND: Visceral artery aneurysms are an uncommon but important form of abdominal vascular disease. This study reviews a contemporary experience with special emphasis on newer methods of diagnosis and treatment. METHODS: From 1980 to 1994, 37 patients were diagnosed with 46 visceral artery aneurysms. These consisted of 22 splenic, 10 hepatic, 4 superior mesenteric, 2 gastroduodenal, 3 celiac, 2 left gastric, 1 pancreatoduodenal, 1 jejunal-ileal, and 1 inferior mesenteric artery aneurysms. Follow-up was complete for 28 patients, average of 37.7 months. There were 17 asymptomatic and 29 symptomatic aneurysms, including 11 presenting with rupture. RESULTS: Seventeen patients were treated surgically, with no surgical deaths. Surgical complications included splenic abscess (two) and failure to thrombose (one). Transcatheter embolization was used in 12 patients. Complications included splenic infarction (one) and recurrence (two), successfully treated with repeat embolization. Nine patients were treated with observation. Eight experienced no complications during follow-up; one died of a ruptured splenic artery aneurysm before treatment was initiated. CONCLUSIONS: The widespread use of computed tomography has led to increased detection of asymptomatic visceral artery aneurysms. Although surgery remains necessary in many patients, transcatheter embolization is effective in the treatment of selected visceral artery aneurysms with few complications and low recurrence.