Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation.

PURPOSE: To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure. MATERIALS AND METHODS: This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta. RESULTS: There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy. CONCLUSIONS: In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.

A multicenter randomized controlled trial indicates that paclitaxel-coated balloons provide no benefit for arteriovenous fistulas.

The role of paclitaxel-coated balloons has been established in the coronary and peripheral arterial circulations with recent interest in the use of paclitaxel-coated balloons to improve patency rates following angioplasty of arteriovenous fistulas. To assess the efficacy of paclitaxel-coated angioplasty balloons to prolong the survival time of target lesion primary patency in arteriovenous fistulas, we designed an investigator-led multi-center randomized controlled trial with follow up time variable for a minimum of one year. Patients with an arteriovenous fistula who were undergoing an angioplasty for a clinical indication were included but patients with one or more lesions outside the treatment segment were excluded. Following successful treatment with a high-pressure balloon, 212 patients were randomized. In the intervention arm, the second component was insertion of a paclitaxel-coated balloon. In the control arm, an identical procedure was followed, but using a standard balloon. The primary endpoint was time to loss of clinically driven target lesion primary patency. Primary analysis showed no significant evidence for a difference in time to end of target lesion primary patency between groups: hazard ratio 1.18 with a 95% confidence interval of 0.78 to 1.79. There were no significant differences for any secondary outcomes, including patency outcomes and adverse events. Thus, our study demonstrated no evidence that paclitaxel-coated balloons provide benefit, following standard care high-pressure balloon angioplasty, in the treatment of arteriovenous fistulas. Hence, in view of the benefit suggested by other trials, the role of paclitaxel-coated angioplasty balloons remains uncertain.

Iliac Fenestration-An Alternative Endovascular Option for Common Iliac Aneurysms.

We report the use of manufacturer-customized fenestrated iliac stent grafts to treat common iliac artery aneurysms (CIAAs) in patients with challenging iliac anatomy, unsuitable for iliac branched devices (IBDs). A 71-year-old woman presented with bilateral CIAAs measuring 44 mm and 29 mm and a perivisceral abdominal aortic aneurysm (AAA). The second patient, a 72-year-old male, had a 42-mm CIAA and an AAA, which expanded to 50 mm during the short-term follow-up. The contralateral internal iliac was occluded. Both patients were deemed high risk for open repair, and endovascular repair was recommended. The aneurysm anatomies were unsuitable for isolated CIAA repair. Suitable sealing zones for endovascular repair were the visceral segment proximally and the external iliac arteries. Preservation of both internal iliac arteries (IIAs) was important to reduce the risk of spinal cord ischemia, but due to distal CIA narrowing, neither patient had sufficient "space" for the branches used in conventional IBD deployment. Three fenestrated Vascutek Anaconda™ iliac limbs were successfully deployed. All three IIAs were preserved with no endoleak, and the patients were discharged after an uneventful postprocedural course. To our knowledge, this is the first successful report of iliac aneurysm repair with manufacturer-customized fenestrated iliac limbs.

The current status of interventional radiology in the undergraduate medical curriculum and the way forward.

Interventional radiology (IR) is underrepresented in undergraduate medical school curricula. Despite the introduction of a suggested undergraduate curriculum for IR by the British Society of Interventional Radiology (BSIR), current evidence suggests there is inadequate knowledge and awareness of IR amongst medical students. As a result of this, there is a lack of visibility of the subspeciality amongst medical students and junior doctors contributing to the shortage of IR trainees resulting in an IR workforce crisis in the UK. The uptake of the proposed undergraduate IR curriculum remains unclear, highlighting the need for a thorough audit and improvement of IR teaching in undergraduate medical education. In this commentary, we discuss the importance of including IR in the undergraduate curriculum, the evidence surrounding undergraduate IR education, the reasons for the potential lack of interest in IR from medical students and future steps to ensure optimal IR exposure in undergraduate medical school curricula.

Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report.

BACKGROUND: Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals. CASE PRESENTATION: A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction. CONCLUSIONS: Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential. LEVEL OF EVIDENCE: Level V, case report.

The Status of Interventional Radiology as a Specialty among Medical Students in India-Knowledge, Interest, and Exposure.

Purpose Interventional radiology (IR) is a young medical specialty where image guidance is utilized in minimally invasive procedures as a treatment option and/or as a diagnostic tool. There is an exponential increase in awareness and interest in IR amongst medical students. This trend is continuing despite lack of proportionate representation of IR in the current medical curriculum. This study aims to understand the exposure to IR as a specialty amongst medical students in India. Materials and Methods Anonymous, voluntary, online questionnaire was sent to medical students from different parts of the country. The survey comprised 15 questions regarding exposure and awareness on IR. Results The responses were obtained from 1,024 medical students from 98 medical colleges across the country, majority (57.0%) in the clinical years of their training. Thirty-six percent of them were interested in an IR career. Lack of awareness was the most (61.6%) cited reason for not choosing an IR career. Majority (57.9%) would consider IR as a clinical management option and believe that IR holds an important place in medical practice (68.4%). Conclusion There is an evident under-representation of IR in the medical curriculum. However, an increasing awareness and interest among medical students toward IR as a specialty is demonstrated. Incorporation of IR into current medical curriculum in a systematic way is the need of the hour. This would ultimately benefit a wide cohort of patients across multiple specialties.

The role of contrast-enhanced ultrasound imaging in the follow-up of patients post-endovascular aneurysm repair.

Endovascular aneurysm repair is a minimally invasive technique for the treatment of abdominal aortic aneurysms. Patients who undergo endovascular aneurysm repair are potentially at risk of developing problems related to the graft such as the development of endoleaks. Endoleaks can cause expansion of the aneurysmal sac, which can potentially lead to rupture. It is for this reason that lifelong surveillance of patients is required to assess the graft and the aneurysmal sac. This article discusses the role of contrast-enhanced ultrasound in the follow-up of patients post-endovascular aneurysm repair. Contrast-enhanced ultrasound is rapidly becoming a powerful, accurate and cost-effective tool to complement computed tomography in the follow-up of endovascular aneurysm repair patients. Real-time imaging of contrast filling into the arterial system means that contrast-enhanced ultrasound is an excellent problem-solving tool, particularly when assessing for the type and anatomy of endoleaks. In some instances, contrast-enhanced ultrasound can detect endoleaks when other modalities are equivocal.

A novel endovascular technique in the management of a large internal iliac artery aneurysm associated with an arteriovenous fistula.

PURPOSE: To describe a novel endovascular technique in the management of a complex arteriovenous fistula between a large internal iliac artery aneurysm and the adjacent iliac vein in a 76-year old patient with previous aortobifemoral bypass graft with an occluded proximal common iliac artery. CASE REPORT: Due to the high risk of open surgery in this case, endovascular treatment with simultaneous venous and arterial access was performed, with implantation of 2 stent grafts in the iliac vein to cover the fistulous communication and embolisation of the native external iliac artery (inflow). CONCLUSION: The endovascular technique described enables thrombosis of the large internal iliac aneurysm and treatment of the arteriovenous fistula without exposing the patient to the high morbidity and mortality associated with open surgery.

Haemobilia--a rare presentation of intrabiliary hydatid disease.

Intrabiliary hydatid cysts have been known to cause complications. We report a rare case of calcified crumpled intrabiliary hydatid cyst causing massive haemobilia due to a hepatic artery pseudoaneurysm, an unusual complication of intrabiliary hydatid cyst. The patient was successfully treated by stenting of the pseudoaneurysm with overlapping stents.

Carotid stump syndrome: pathophysiology and endovascular treatment options.

Carotid stump syndrome is one of the recognised causes of recurrent ipsilateral cerebrovascular events after occlusion of the internal carotid artery. It is believed that microemboli arising from the stump of the occluded internal carotid artery or the ipsilateral external carotid artery can pass into the middle cerebral artery circulation as a result of patent external carotid-internal carotid anastomotic channels. Different pathophysiologic causes of this syndrome and endovascular options for treatment are discussed.

Transvenous embolization to treat uncontrolled hemobilia and peritoneal bleeding after transjugular liver biopsy.

Hemobilia is one of the complications that can occur after a transjugular liver biopsy. Various treatment options have been described for the management of this condition, including transarterial embolization and open surgery. We describe a patient who developed uncontrolled hemobilia after a transjugular liver biopsy that required a transvenous approach for embolization and treatment purposes.

Magnetic resonance angiography: current status in the planning and follow-up of endovascular treatment in lower-limb arterial disease.

Magnetic resonance angiography (MRA) has become an established imaging modality in the management of lower-limb arterial disease, with emerging roles in treatment planning and follow-up. Contrast-enhanced MRA is now the most widely used technique with clinically acceptable results in the majority of patients. Difficulties in imaging and image interpretation are recognised in certain subgroups, including patients with critical limb ischaemia as well as patients with stents. Although newer contrast agents and refined imaging protocols may offer some solutions to these problems, this optimism is balanced by concerns about the toxicity of certain gadolinium chelates. Further development of interventional MRA remains one of the most significant challenges in the development of magnetic resonance imaging-guided peripheral vascular intervention. The status of MRA in managing patients with lower-limb arterial disease in current clinical practice is reviewed.