Survival analysis of risk factors for major recurrence of intracranial aneurysms after coiling.

BACKGROUND: Recurrence after intracranial aneurysm coiling is a highly prevalent outcome, yet to be understood. We investigated clinical, radiological and procedural factors associated with major recurrence of coiled intracranial aneurysms. METHODS: We retrospectively analyzed prospectively collected coiling data (2003-12). We recorded characteristics of aneurysms, patients and interventional techniques, pre-discharge and angiographic follow-up occlusion. The Raymond-Roy classification was used; major recurrence was a change from class I or II to class III, increase in class III remnant, and any recurrence requiring any type of retreatment. Identification of risk factors associated with major recurrence used univariate Cox Proportional Hazards Model followed by multivariate regression analysis of covariates with P<0.1. RESULTS: A total of 467 aneurysms were treated in 435 patients: 283(65%) harboring acutely ruptured aneurysms, 44(10.1%) patients died before discharge and 33(7.6%) were lost to follow-up. A total of 1367 angiographic follow-up studies (range: 1-108 months, Median [interquartile ranges (IQR)]: 37[14-62]) was performed in 384(82.2%) aneurysms. The major recurrence rate was 98(21%) after 6(3.5-22.5) months. Multivariate analysis (358 patients with 384 aneurysms) revealed the risk factors for major recurrence: age>65 y (hazard ratio (HR): 1.61; P=0.04), male sex (HR: 2.13; P<0.01), hypercholesterolemia (HR: 1.65; P=0.03), neck size ≥4 mm (HR: 1.79; P=0.01), dome size ≥7 mm (HR: 2.44; P<0.01), non-stent-assisted coiling (HR: 2.87; P=0.01), and baseline class III (HR: 2.18; P<0.01). CONCLUSION: Approximately one fifth of the intracranial aneurysms resulted in major recurrence. Modifiable factors for major recurrence were choice of stent-assisted technique and confirmation of adequate baseline occlusion (Class I/II) in the first coiling procedure.

Outpatient uterine artery embolization for symptomatic fibroids: short- and long-term single institution-based outcomes.

OBJECTIVE: To assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis. METHODS: One hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded. RESULTS: UAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory. CONCLUSION: UAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.

Clinical and angiographic outcomes of stent-assisted coiling of intracranial aneurysms.

BACKGROUND: Despite the increasing use of stent-assisted coiling (SAC), data on its long-term clinical and angiographic results are limited. OBJECTIVE: The objective of this article is to assess the long-term clinical and angiographic outcomes in SAC in our single-center practice. METHODS: We conducted a retrospective analysis of intracranial aneurysms treated with detachable coils during the period 2003-2012. Patients were divided into SAC and non-SAC groups and were analyzed for aneurysm occlusion, major recurrence and clinical outcome. Logistic regression analyses identified factors associated with clinical/angiographic outcomes (p value <0.05 was statistically significant). RESULTS: A total of 516 procedures met inclusion criteria: Sixty-three (12.2%) patients underwent SAC, of whom 56 (89%) had an elective procedure whereas 286 (63.1%) aneurysms from the non-SAC group were ruptured. In the unruptured subcohort, baseline class I was achieved in 24 (38%, p = 0.91), and predischarge modified Rankin scale score (mRS) 0-2 was obtained in 96.4% of cases in the SAC group versus 90.4% in the non-stent group. The major recurrence was 9.5% versus 11.3% in the SAC and non-SAC group, respectively (p = 0.003). At last clinical assessment, 98.2% of the patients from the unruptured SAC group had mRS 0-2 (mean follow-up, 58 months) versus 93.6% (mean follow-up, 56 months) in the unruptured non-SAC group (p = 0.64). Periprocedural vasospasm was associated with long-term poor outcome in the unruptured SAC subcohort (p = 0.0008). CONCLUSIONS: SAC and non-SCA techniques show comparable safety and clinical outcome. The SAC technique significantly decreases retreatment rates. Periprocedural vasospasm resulting from vessel manipulation is associated with poor outcome in SAC of unruptured aneurysms.

Failed attempts and improvement strategies in peripheral intravenous catheterization.

BACKGROUND: Access to peripheral veins is necessary for sample collection, transfusion and infusion of fluids or medications. The peripheral intravenous catheterization (PIVC) procedure is the introduction of a short catheter into a peripheral vein and can be problematic, leading to multiple failed attempts. PURPOSE: To analyze scientific literature regarding difficulties in establishing peripheral intravenous access and improvement strategies. METHOD: A literature search was undertaken and secondary references were retrieved from the papers obtained from the initial search. A total of 128 papers published from 1975 to 2011 were reviewed. RESULTS: The first attempt of PIVC fails in 12-26% of adults and 24-54% of children. Factors associated with the currently utilized PIVC success include: (1) patient's characteristics such as age, gender, race, weight/BMI, co-existing medical conditions and skin/vein characteristics, (2) procedure related factors such as the insertion site and catheter caliber, and (3) the operator's expertise. Strategies to improve PIVC success include: (1) bedside techniques such as venodilation, vascular visualization and vein entry indication, (2) pain management and (3) engagement of expert health care providers. CONCLUSION: Bedside techniques have shown more improvement in PIVC success rates as opposed to pain management. Expert health care providers have shown higher performance levels with regard to the difficult cases of PIVC.