David Hovsepian

Abstract

Compression of the left common iliac vein (CIV; LCIV) is a known risk factor for lower-extremity deep vein thrombosis (DVT). This study was performed to model the probability of DVT based on LCIV diameter and apply this to a quantitative DVT risk factor scoring system.Medical records were used to identify female patients younger than 45 years of age who were diagnosed with lower-extremity DVT (n = 21) and age-matched control subjects (n = 26) who presented to the emergency department with abdominal pain. Minimum CIV diameters were measured on computed tomography. Based on published reporting standards, 13 risk factors were scored for patients diagnosed with left-sided DVT and for control subjects. The association between vein diameter and DVT was examined by Mann-Whitney test. Odds of DVT based on vein diameter was assessed by logistic regression.Mean minimum LCIV diameters were 4.0 mm for patients with DVT and 6.5 mm for patients without DVT (P = .001). The odds of left DVT increased by a factor of 1.68 for each millimeter decrease in LCIV diameter (odds ratio = 1.68; P = .006; 95% confidence interval, 1.16-2.43). As the risk factor score increased, the relationship between diameter and risk for DVT became stronger; identical LCIV diameters were associated wtih a higher probability of developing DVT if the risk factor score was higher.Stenosis of the LCIV was found to be a strong independent risk factor for development of DVT. Moreover, each millimeter decrease in CIV diameter increased the odds of DVT by a factor of 1.68.

View details for DOI 10.1016/j.jvir.2012.07.030

View details for Web of Science ID 000311267900011

View details for PubMedID 23101919

Abstract

A 44-year-old woman underwent uncomplicated uterine fibroid embolization (UFE) for menstrual and bulk-related symptoms in an enlarged, myomatous uterus. After surgery, she spontaneously sloughed a large mass of fibroids that arrested in the cervical canal during passage. Four days after gynecological extraction, she developed copious vaginal discharge that contained enteric contents. Contrast-enhanced computed tomography (CT) demonstrated a fistula between the small bowel and the uterus. She subsequently underwent hysterectomy, left oophorectomy, and small-bowel resection. Her postoperative recovery was uneventful.

View details for DOI 10.1007/s00270-011-0318-4

View details for Web of Science ID 000308950200035

View details for PubMedID 22159908

Abstract

We evaluated the safety and effectiveness of alternative endovascular methods to retrieve embedded optional and permanent filters in order to manage or reduce risk of long-term complications from implantation. Histologic tissue analysis was performed to elucidate the pathologic effects of chronic filter implantation.We studied the safety and effectiveness of alternative endovascular methods for removing embedded inferior vena cava (IVC) filters in 10 consecutive patients over 12 months. Indications for retrieval were symptomatic chronic IVC occlusion, caval and aortic perforation, and/or acute PE (pulmonary embolism) from filter-related thrombus. Retrieval was also performed to reduce risk of complications from long-term filter implantation and to eliminate the need for lifelong anticoagulation. All retrieved specimens were sent for histologic analysis.Retrieval was successful in all 10 patients. Filter types and implantation times were as follows: one Venatech (1,495 days), one Simon-Nitinol (1,485 days), one Optease (300 days), one G2 (416 days), five Günther-Tulip (GTF; mean 606 days, range 154-1,010 days), and one Celect (124 days). There were no procedural complications or adverse events at a mean follow-up of 304 days after removal (range 196-529 days). Histology revealed scant native intima surrounded by a predominance of neointimal hyperplasia and dense fibrosis in all specimens. Histologic evidence of photothermal tissue ablation was confirmed in three laser-treated specimens.Complex retrieval methods can now be used in select patients to safely remove embedded optional and permanent IVC filters previously considered irretrievable. Neointimal hyperplasia and dense fibrosis are the major components that must be separated to achieve successful retrieval of chronic filter implants.

View details for DOI 10.1007/s00270-011-0175-1

View details for Web of Science ID 000304162700018

View details for PubMedID 21562933

Abstract

To determine the feasibility and efficacy of applying an established innovation process to an active academic interventional radiology (IR) practice.The Stanford Biodesign Medical Technology Innovation Process was used as the innovation template. Over a 4-month period, seven IR faculty and four IR fellow physicians recorded observations. These observations were converted into need statements. One particular need relating to gastrostomy tubes was diligently screened and was the subject of a single formal brainstorming session.Investigators collected 82 observations, 34 by faculty and 48 by fellows. The categories that generated the most observations were enteral feeding (n = 9, 11%), biopsy (n = 8, 10%), chest tubes (n = 6, 7%), chemoembolization and radioembolization (n = 6, 7%), and biliary interventions (n = 5, 6%). The output from the screening on the gastrostomy tube need was a specification sheet that served as a guidance document for the subsequent brainstorming session. The brainstorming session produced 10 concepts under three separate categories.This formalized innovation process generated numerous observations and ultimately 10 concepts to potentially to solve a significant clinical need, suggesting that a structured process can help guide an IR practice interested in medical innovation.

View details for DOI 10.1016/j.jvir.2011.12.029

View details for Web of Science ID 000302396300009

View details for PubMedID 22464713

View details for DOI 10.1007/s10620-011-1945-y

View details for Web of Science ID 000300578200005

View details for PubMedID 22021052

Abstract

To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

View details for DOI 10.1016/j.jvir.2011.09.030

View details for Web of Science ID 000299151400015

View details for PubMedID 22133709

Abstract

To prospectively evaluate the impact of C-arm CT on radiation exposure to hepatocellular carcinoma (HCC) patients treated by chemoembolization.Patients with HCC (N = 87) underwent digital subtraction angiography (DSA; control group) or combined C-arm CT/DSA (test group) for chemoembolization. Dose-area product (DAP) and cumulative dose (CD) were measured for guidance and treatment verification. Contrast agent volume and C-arm CT utility were also measured.The marginal DAP increase in the test group was offset by a substantial (50%) decrease in CD from DSA. Use of C-arm CT allowed reduction of DAP and CD from DSA imaging (P = .007 and P = .017). Experienced operators were more efficient in substituting C-arm CT for DSA, resulting in a negligible increase (7.5%) in total DAP for guidance, compared with an increase of 34% for all operators (P = .03). For treatment verification, DAP from C-arm CT exceeded that from DSA, approaching that of conventional CT. The test group used less contrast medium (P = .001), and C-arm CT provided critical or supplemental information in 20% and 17% of patients, respectively.Routine use of C-arm CT can increase stochastic risk (DAP) but decrease deterministic risk (CD) from DSA. However, the increase in DAP is operator-dependent, thus, with experience, it can be reduced to under 10%. C-arm CT provides information not provided by DSA in 33% of patients, while decreasing the use of iodinated contrast medium. As with all radiation-emitting modalities, C-arm CT should be used judiciously.

View details for DOI 10.1016/j.jvir.2011.07.008

View details for Web of Science ID 000296661800008

View details for PubMedID 21875814

Abstract

Before yttrium-90 ((90)Y) radioembolization administration, the authors consolidated arterial inflow by embolizing variant hepatic arteries (HAs) to make microsphere delivery simpler and safer. The present study reviews the technical and clinical success of these consolidation procedures.Preparatory and treatment angiograms were retrospectively analyzed for 201 patients. Variant HAs were coil-embolized during preparatory angiography to simplify arterial anatomy. Collateral arterial perfusion of territories previously supplied by variant HAs was evaluated by digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) scintigraphy, and by follow-up evaluation of regional tumor response.A total of 47 variant HAs were embolized in 43 patients. After embolization of variant HAs, cross-perfusion into the embolized territory was depicted by DSA and by C-arm CT in 100% of patients and by (99m)Tc-MAA scintigraphy in 92.7%. Uniform progressive disease prevented evaluation in 33% of patients, but regional tumor response in patients who responded supported successful delivery of microspheres to the embolized territories in 95.5% of evaluable patients.Embolization of variant HAs for consolidation of hepatic supply in preparation for (90)Y radioembolization promotes treatment of affected territories via intrahepatic collateral channels.

View details for DOI 10.1016/j.jvir.2011.06.014

View details for Web of Science ID 000295708400004

View details for PubMedID 21961981

Abstract

To perform embolization of parasitized extrahepatic arteries (EHAs) before radioembolization to reestablish intrahepatic arterial supply to large, peripheral tumors, and to evaluate the technical and clinical outcomes of this intervention.Among 201 patients retrospectively analyzed, embolization of 73 parasitized EHAs in 35 patients was performed. Most embolization procedures were performed during preparatory angiography using large particles and coils. Digital subtraction angiography (DSA), C-arm computed tomography (CT), and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy were used to evaluate the immediate perfusion via intrahepatic collateral channels of target tumor areas previously supplied by parasitized EHAs. Follow-up imaging of differential regional tumor response was used to evaluate microsphere distribution and clinical outcome.After embolization, reestablishment of intrahepatic arterial supply was confirmed by both DSA and C-arm CT in 94% of territories and by scintigraphy in 96%. In 32% of patients, the differential response of treatment could not be evaluated because of uniform disease progression. However, symmetric regional tumor response in 94% of evaluable patients indicated successful delivery of microspheres to the territories previously supplied by parasitized EHAs.Reestablishment of intrahepatic arterial inflow to hepatic tumors by embolization of parasitized EHAs is safe and effective and results in successful delivery of yttrium-90 microspheres to tumors previously perfused by parasitized EHAs.

View details for DOI 10.1016/j.jvir.2011.06.007

View details for Web of Science ID 000295708400002

View details for PubMedID 21961979

Abstract

Patients with autogenous native vessel portosystemic shunts, whether surgical or congenital, may experience complications of excess shunt flow, including hepatopulmonary syndrome (HPS), hepatic encephalopathy (HE), and hepatic insufficiency. The authors explored endovascular reduction or occlusion of autogenous portosystemic shunts using methods commonly employed in transjugular intrahepatic portosystemic shunt (TIPS) reduction in four pediatric patients. Before treatment, the patients had hypoplastic, atrophic, or thrombosed portal veins. Following intervention, symptoms of overshunting resolved or improved in all patients without major complications. The innate plasticity of the pediatric portal venous system allowed for hypertrophy or development and maturation of cavernous transformations to accommodate increased hepatopetal blood flow and pressure.

View details for DOI 10.1016/j.jvir.2011.01.438

View details for Web of Science ID 000293482700020

View details for PubMedID 21801995

Abstract

To evaluate the safety and effectiveness of the excimer laser sheath technique for removing embedded inferior vena cava (IVC) filters.Over 12 months, 25 consecutive patients undergoing attempted IVC filter retrieval with a laser-assisted sheath technique were prospectively enrolled into an institutional review board-approved study registry. There were 10 men and 15 women (mean age 50 years, range 20-76 years); 18 (72%) of 25 patients were referred from an outside hospital. Indications for retrieval included symptomatic filter-related acute caval thrombosis (with or without acute pulmonary embolism), chronic IVC occlusion, and bowel penetration. Retrieval was also performed to remove risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After failure of standard methods, controlled photothermal ablation of filter-adherent tissue with a Spectranetics laser sheath and CVX-300 laser system was performed. All patients were evaluated with cavography, and specimens were sent for histologic analysis.Laser-assisted retrieval was successful in 24 (96%) of 25 patients as follows: 11 Günther Tulip (mean 375 days, range 127-882 days), 4 Celect (mean 387 days, range 332-440 days), 2 Option (mean 215 days, range 100-330 days), 4 OPTEASE (mean 387 days, range 71-749 days; 1 failed 188 days), 2 TRAPEASE (mean 871 days, range 187-1,555 days), and 2 Greenfield (mean 12.8 years, range 7.2-18.3 years). There was one (4%) major complication (acute thrombus, treated with thrombolysis), three (12%) minor complications (small extravasation, self-limited), and one adverse event (coagulopathic retroperitoneal hemorrhage) at follow-up (mean 126 days, range 13-302 days). Photothermal ablation of filter-adherent tissue was histologically confirmed in 23 (92%) of 25 patients.The laser-assisted sheath technique appears to be a safe and effective tool for retrieving embedded IVC filters, including permanent types, with implantation ranging from months to > 18 years.

View details for DOI 10.1016/j.jvir.2011.01.459

View details for Web of Science ID 000291414500011

View details for PubMedID 21530309

View details for DOI 10.1016/j.jvir.2010.12.031

View details for Web of Science ID 000289340100024

View details for PubMedID 21463762

Abstract

To test the hypothesis that a common iliac vein (CIV) stenosis may impair embolization of a large deep venous thrombosis (DVT) to the lungs, decreasing the incidence of a symptomatic pulmonary embolism (PE).Between January 2002 and August 2007, 75 patients diagnosed with unilateral DVT were included in a single-institution case-control study. Minimum CIV diameters were measured 1 cm below the inferior vena cava (IVC) bifurcation on computed tomography (CT) images. A significant stenosis in the CIV ipsilateral to the DVT was defined as having either a diameter 4 mm or less or a greater than 70% reduction in lumen diameter. A symptomatic PE was defined as having symptoms and imaging findings consistent with a PE. The odds of symptomatic PE versus CIV stenosis were assessed using logistic regression models. The associations between thrombus location, stenosis, and symptomatic PE were assessed using a stratified analysis.Of 75 subjects, 49 (65%) presented with symptomatic PE. There were 17 (23%) subjects with a venous lumen 4 mm or less and 12 (16%) subjects with a greater than 70% stenosis. CIV stenosis of 4 mm or less resulted in a decreased odds of a symptomatic PE compared with a lumen greater than 4 mm (odds ratio [OR] 0.17, P = .011), whereas a greater than 70% stenosis increased the odds of DVT involving the CIV (OR 7.1, P = .047).Among patients with unilateral DVT, those with an ipsilateral CIV lumen of 4 mm or less have an 83% lower risk of developing symptomatic PE compared with patients with a CIV lumen greater than 4 mm.

View details for DOI 10.1016/j.jvir.2010.10.009

View details for Web of Science ID 000287166600004

View details for PubMedID 21276911

Abstract

To enhance the educational experience among residents rotating through interventional radiology (IR) by encouraging ownership and responsibility.In May 2006, the authors implemented changes in resident education in IR that included increased clinical responsibilities, structured didactics, and greater hands-on experience, including call. Residents were assigned as first assistants, ownership of cases was encouraged, and assignment to a week on the consult service was instituted to help residents better understand all aspects of IR practice. Additional faculty recruitment and program expansion ensured the same high level of training for the fellowship program. Evaluations were reviewed every year (July 1, 2007-June 30, 2009) for hands-on training, daily teaching, didactic conferences, and overall effectiveness of the clinical service. A graduated scale of 1-5 was used.In 2009, 3 years after the curricular changes were made, the quality of hands-on training, daily case reviews and consults, didactics, and overall education had markedly improved with 89%, 71%, 65%, and 82% of the residents rating these respective aspects of the training as "above expectations" (4 on a scale of 5) or "superior" (5 on a scale of 5) compared with 77%, 23%, 20%, and 60% in 2005-2006. Three years after the changes, the impact of these changes on recruitment patterns also showed improvement, with 28.6% of the class of 2010 pursuing a fellowship in IR.Increasing resident ownership, responsibility, and hands-on experience improves resident education in IR, which, in turn, promotes interest in the field.

View details for DOI 10.1016/j.jvir.2010.07.009

View details for Web of Science ID 000284244200009

View details for PubMedID 20884234

Abstract

Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization.One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization.Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038).Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.

View details for DOI 10.1016/j.jvir.2010.04.030

View details for Web of Science ID 000281620600012

View details for PubMedID 20688531

Abstract

As health care quality continues to move into the limelight, so do physicians. The new Joint Commission requirements (Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation) mandate continuous data-based evaluation and monitoring of physician practice performance. This task could be seen as cumbersome, but it may provide opportunities to develop quality improvement programs that demonstrate the value provided by hospital-based radiologists.

View details for DOI 10.1016/j.jacr.2010.01.027

View details for PubMedID 20522395

View details for DOI 10.1016/j.jvir.2010.01.010

View details for Web of Science ID 000277666000003

View details for PubMedID 20299244

Abstract

The goals and current efforts of the Radiological Society of North America Radiology Reporting Committee are described. The committee's charter provides an opportunity to improve the organization, content, readability, and usefulness of the radiology report and to advance the efficiency and effectiveness of the reporting process.

View details for DOI 10.1148/radiol.2523081992

View details for Web of Science ID 000270809500028

View details for PubMedID 19717755

View details for DOI 10.1016/j.jvir.2009.04.016

View details for Web of Science ID 000267613200006

View details for PubMedID 19560003

View details for DOI 10.1016/j.jvir.2009.04.033

View details for PubMedID 19560002

View details for DOI 10.1016/j.jvir.2009.04.005

View details for Web of Science ID 000267613200003

View details for PubMedID 19560000

View details for DOI 10.1016/j.jvir.2009.04.006

View details for Web of Science ID 000267613200002

View details for PubMedID 19559999

View details for DOI 10.1016/j.jvir.2009.04.002

View details for PubMedID 19560015

Abstract

To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy.From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation.The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation.Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

View details for DOI 10.1016/j.jvir.2008.09.026

View details for Web of Science ID 000263075000012

View details for PubMedID 19019700

Abstract

Stereology is a simple, fast method for object segmentation that involves counting the number of intersections of a randomly positioned grid over an object. The objectives of this study were to determine observer reliability in making stereologic- and ellipsoid-based measurements of uterine and leiomyoma volumes and to test the agreement between these two methods of measurement.Two observers made uterine and dominant leiomyoma volume measurements on MR images in 30 patients using stereology and the popular ellipsoid-based technique. Stereologic volume measurements were made from high-resolution T2 images in two perpendicular planes (axial and sagittal). Ellipsoid volume was calculated by multiplying the maximal sagittal, anteroposterior, and transverse dimensions by pi/6. For these measurements, interobserver reliability was tested with paired t-tests and percent differences were determined. A mean stereologic volume and a mean ellipsoid volume were determined and tested for agreement with a paired t-test. Percent differences were also calculated.Stereologic measurements demonstrated excellent interobserver reliability with 0.3% difference in mean uterine volumes (P = .69) and 0.3% difference (P = .81) in mean leiomyoma volumes. The ellipsoid method resulted in poorer interobserver reliability with 7% difference (P = .01) in mean uterine volumes and 4% difference (p = .24) in mean leiomyoma volumes. The ellipsoid method also significantly overestimated uterine volumes by 14% (P < .01) compared with stereology.Stereology provided high interobserver reliability for leiomyoma and overall uterine volume measurements and was more reliable than the ellipsoid method, which uses linear measurements. Stereology appears well suited when precise volume measurements are desired for assessing response to uterine arterial embolization treatments.

View details for DOI 10.1016/j.acra.2007.01.004

View details for Web of Science ID 000245576800013

View details for PubMedID 17368215

View details for PubMedID 17412251

Abstract

To report our 12-year experience with radiological treatment (ureteric embolization) for refractory urinary fistula, as malignancy, radiation therapy, and/or chronic inflammation increase the risk of lower urinary tract fistula after surgical urinary diversion, which can lead to significant morbidity, and for patients who are not surgical candidates permanent nephrostomy drainage and ureteric embolization offer an alternative form of urinary diversion.We retrospectively reviewed patients who had ureteric occlusion for refractory urinary fistula at our institution between 1993 and 2005. Stainless-steel coils, with or without gelatine sponge, were placed antegradely through a percutaneous nephrostomy tract. Patients were then managed by long-term nephrostomy drainage until death or definitive reconstructive surgery.In all, 29 patients (23 women and six men; mean age 59 years, sd 16) were identified who had urinary fistulae that were refractory to nephrostomy drainage alone. One patient had a history of severe perineal trauma and the remaining 28 had a history of cancer. Seventeen fistulae occurred in the setting of previous surgery, 20 patients had received adjunctive pelvic irradiation and 11 had had chemotherapy. In all, 52 ureters were embolized; occlusion was successful in all cases, with complete or near-complete (<1 pad/day) dryness within 3 days. No repeat embolization was required and there were no significant complications. Two patients were lost to follow-up. Three patients had definitive urinary diversion surgery and currently are well. One patient is alive and living with nephrostomy tubes; 23 patients have died.Ureteric embolization is a viable option for managing complex lower urinary tract fistulae in patients with a poor performance status. It can be used as definitive management in patients with a limited life-expectancy or as a temporary measure in those for whom another management plan is anticipated.

View details for DOI 10.1111/j.1464-410X.2006.06569.x

View details for Web of Science ID 000243411700026

View details for PubMedID 17026590

View details for DOI 10.1097/01.RVI.0000251151.01365.C1

View details for Web of Science ID 000243281500001

View details for PubMedID 17185681

Abstract

To prospectively compare uterine artery embolization (UAE) versus myomectomy and hysterectomy with regard to ovarian function as measured by postprocedure follicle-stimulating hormone (FSH) levels and symptoms.Fifty-five patients were prospectively enrolled in the study: 33 patients who underwent UAE, seven who underwent myomectomy, and 15 who underwent hysterectomy. Patients had serum FSH and estradiol levels measured on the third day of the menstrual cycle before their procedure and at regular follow-up visits for as long as 6 months. At these intervals, patients were also surveyed regarding menopausal symptoms.Although a mild transient increase in mean FSH level after UAE was noted at 3 months, there were no statistically significant differences among the three groups in mean FSH levels at 1 month, 3 months, or 6 months of follow-up. Menopausal symptoms arose in the UAE and hysterectomy groups, but there was no statistically significant difference or permanent effect in either group.There is no significant difference in impact on ovarian function after UAE, hysterectomy, or myomectomy at follow-up for a maximum of 6 months.

View details for DOI 10.1097/01.RVI.0000228338.11178.C8

View details for Web of Science ID 000239548900008

View details for PubMedID 16868163

Abstract

The primary purpose of the present study was to compare the antiinflammatory effectiveness of rofecoxib with that of ibuprofen in the first 5 days after uterine artery embolization (UAE). The secondary aim was to compare pain levels and narcotic use among patients treated with different embolic agents.From July 2003 to June 2004, 68 UAE procedures were performed by one of the authors (D.M.H.). Of this group, 50 women agreed to participate in this study. Exclusion criteria were limited to contraindication to either drug or current steroid or nonsteroidal antiinflammatory drug use. In a randomized, double-blinded fashion, patients received a numbered pill box that contained one of the two agents and its placebo counterpart. Four times per day for 5 days, patients recorded their level of pain on a visual analog scale and the amount of narcotic analgesic drug needed at that time. Score sheets were returned by mail after completion. During the course of the study, three embolic agents (Gold Embospheres, Contour SE particles, and Embospheres) were used in succession, with similar numbers of patients in each group.Four patients were excluded from analysis: two who were readmitted to the hospital for treatment of pain (one treated with each antiinflammatory medication) and two who failed to complete their score sheets. Subject demographics were very similar with respect to antiinflammatory drug treatment and embolic agent, except that the average age of patients in the Embosphere group was 6 years older than in the Embosphere Gold and Contour SE groups (P= .02). There was no difference in the pain level and narcotic drug intake between the two drug arms, but among embolic agents, the Embosphere Gold group tended to have a higher overall average pain score (P = .12), and the two patients readmitted were in this group. Patients in the Contour SE group tended to use a lower amount of narcotic drug than those in the other two embolic agent groups (P = .09).There was no difference between rofecoxib and ibuprofen with respect to postprocedural pain or narcotic use after UAE. Embolic agent appeared to have a greater impact, with patients in the Embosphere Gold group reporting higher pain scores and those in the Contour SE group requiring a lower amount of narcotic drug than those in the Embosphere Gold or Embosphere groups.

View details for DOI 10.1097/01.RVI.0000208986.80383.4C

View details for Web of Science ID 000236836700010

View details for PubMedID 16614150

View details for DOI 10.1007/s00270-005-0243-5

View details for Web of Science ID 000234728900001

View details for PubMedID 16391950

Abstract

Catheter-directed embolization has become a widespread technique for the treatment of benign and malignant neoplasms. The mechanism whereby embolization leads to selective atrophy of these neoplasms is largely speculative. As a potential model for the large regional perfusion differences between normal and neoplastic tissues, renal perfusion was studied before and after catheter-directed embolization. The working hypothesis was that embolization would create measurable changes in blood flow in the renal cortex and medulla.Microspheres (l0 microm in diameter) containing a series of different fluorophores were injected into the arterial system before and after the renal arteries were embolized with a series of larger (100-300 microm) particulate embolic agents. The distribution of the microspheres in the renal cortex, renal medulla, and liver was analyzed by fluorescence microscopy as well as by extraction of the fluorophores.The distribution of the fluorescent microspheres was readily assessed by fluorescence microscopy or extraction of the fluorophores. Before embolization, the renal cortex received approximately three times more flow than the medulla. After embolization, perfusion of the renal cortex and medulla decreased in parallel.Fluorescent microspheres are a powerful tool for measuring the changes in flow that occur after catheter-directed embolization. The fact that parallel decreases in flow were found in the renal cortex and medulla indicates that the distribution of each embolic agent was flow-directed. These results might provide insight into the mechanism of tumor atrophy after uterine artery embolization or hepatic chemoembolization.

View details for DOI 10.1097/01.RVI.0000195398.70290.BE

View details for Web of Science ID 000236517800012

View details for PubMedID 16415139

Abstract

Uterine artery embolization (UAE) is assuming an important role in the treatment of women with symptomatic uterine leiomyomata worldwide. The following guidelines, which have been jointly published with the Society of Interventional Radiology in the Journal of Vascular and Interventional Radiology, are intended to ensure the safe practice of UAE by identifying the elements of appropriate patient selection, anticipated outcomes, and recognition of possible complications and their timely address.

View details for DOI 10.1007/s00270-004-0087-4

View details for Web of Science ID 000223043900002

View details for PubMedID 15346204

View details for DOI 10.1097/01.RVI.0000127893.00553.CC

View details for Web of Science ID 000227678200002

View details for PubMedID 15178712

Abstract

The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 mm or more.Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent (>or=6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery.Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7 +/- 16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2 +/- 8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type II endoleak associated with aneurysm sac growth was US dollars 6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of US dollars 200000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months.Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.

View details for DOI 10.1016/j.jvs.2003.10.026

View details for Web of Science ID 000188535000008

View details for PubMedID 14743129

View details for DOI 10.1097/01.RVI.0000109408.52762.35

View details for Web of Science ID 000228600400002

View details for PubMedID 14963177

Abstract

To determine the pregnancy outcomes in patients undergoing fallopian tube recanalization (FTR) with use of oil-based versus water-soluble contrast agents.Ninety-three patients with unilateral or bilateral proximal tubal occlusion confirmed by hysterosalpingography or laparoscopy underwent FTR with use of water-soluble contrast material alone (n = 50) or also had an oil-based agent injected into each tube after recanalization (n = 43). Pregnancy rates and outcomes of the two groups were studied retrospectively.With respect to differences between groups, only the body mass index proved to be a significant predictor (oil, 28.4; water, 24.7; P =.008). Mean age, duration of infertility, type of infertility, and initial diagnosis were comparable. There was a weak trend toward a higher pregnancy rate in the oil-based contrast material group, but it was not significant (P =.64). The average time to pregnancy was 4.4 months with use of oil-based contrast material, compared to 7.7 months with use of only water-soluble contrast material (P =.03).The use of an oil-based agent had little effect on the rate of conception, but time to conception was reduced by more than 3 months.

View details for DOI 10.1097/01.RVI.0000052293.26939.10

View details for Web of Science ID 000180962200009

View details for PubMedID 12525588

Abstract

To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis.Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded.Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006).The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

View details for Web of Science ID 000178820700005

View details for PubMedID 12397121

Abstract

Percutaneous closure devices are used in as many as 30% of all endovascular studies. Despite widespread use of these devices, only limited imaging has been performed after percutaneous closure. In this study, arteriograms of patients who had undergone suture-mediated closure with the Perclose device were reviewed.Between June 1998 and November 2001, 31 patients who had previously undergone closure with use of the Perclose device at our institution returned for additional angiographic procedures. Twenty-one patients underwent closure with use of the Perclose device after embolization, including hepatic artery chemoembolization (n = 18), treatment of hypervascular sacral metastases (n = 2), and bronchial artery embolization (n = 1). Nineteen of these patients had thrombocytopenia. Ten patients underwent closure with use of the Perclose device after diagnosis and treatment of peripheral vascular disease.Of 31 patients, 28 had normal follow-up studies, including one patient who underwent four previous closures. These 28 patients all had normal femoral artery caliber at initial angiography and a platelet count of more than 18,000/mm(3). Two patients with preexisting atherosclerotic change had progression of disease at the puncture site and a third with severe thrombocytopenia developed a small asymptomatic posterolateral pseudoaneurysm.In patients with normal femoral arteries, the long-term effects of closure with use of the Perclose device, even performed multiple times, appears to be minimal.

View details for Web of Science ID 000177228700002

View details for PubMedID 12119324

Abstract

Women account for approximately 25% of patients with AAAs, but unfortunately, only 8-10% of patients considered candidates for endovascular treatment during prospective trials were women. We reviewed our experience with open surgical and endovascular techniques before and after the FDA approval of the Ancure and AneuRx devices to evaluate our results and the role of endovascular treatment of AAAs in women. From January 1999 to August 2000, 269 patients underwent elective repair of their AAAs at our institution. The 20-month period was divided into the 10 months before and after the FDA approval of the endovascular devices for comparison. In the initial time period, 75 patients (62 men and 13 women) underwent repair with 40% undergoing endovascular repair. In the 10 months after FDA approval, 194 patients (160 men and 34 women) underwent repair with 87% undergoing endovascular treatment. Ninety-two percent (155) of the patients undergoing endovascular repair in this period were treated with the AneuRx device. These 155 patients were divided into two groups based on gender to compare their early treatment results. The FDA approval of endovascular grafts has profoundly affected the treatment of infrarenal AAAs in the United States. Women continue to account for a small, but complex, proportion of patients treated with available endovascular devices and the results in these patients is worse than their male counterparts. Careful patient selection and meticulous operative techniques are needed to reliably treat women with available endovascular devices. Further developments are necessary to improve the current results and increase the proportion of women being safely and effectively treated with endovascular devices.

View details for DOI 10.1007/s10016-001-0176-7

View details for Web of Science ID 000177802500005

View details for PubMedID 12134216

Abstract

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

View details for PubMedID 12098108

Abstract

Patients generally notice some relief of both menorrhagia and mass-effect symptoms during the first few weeks after uterine fibroid embolization (UFE). Shrinkage of the fibroids continues to take place over several months, peaking somewhere between 3 and 6 months, with measurable shrinkage sometimes noted for up to 1 year. The timing of follow-up visits is intended to coincide with the time course of improvement so that diagnostic imaging and intervention can be performed if symptoms worsen or relief does not appear to be on schedule. The amount of shrinkage of fibroids correlates neither with the intensity of immediate postprocedure symptoms or the degree of symptom relief. Affected fibroids undergo hyaline degeneration, a process in which the hard, cellular tumor is replaced by softer, acellular material. A nationwide registry has been constructed for the accumulation of procedural and follow-up data so that success and complication rates can be accurately determined and long-term issues about the durability of UFE and possible side effects can be addressed.

View details for PubMedID 12098107

Abstract

Successful superselective catheterization of the uterine artery requires familiarity with female pelvic arterial anatomy, knowledge of effective catheter and guidewire combinations, and a few tricks. A learning curve can be expected for each of these elements, although it is assumed that the operator will already have experience in basic catheter techniques. Safe transcatheter delivery, understanding of embolization end points, and avoidance of nontarget embolization are essential. Equally important are knowledge of the properties of the embolic agents currently available and their indications for use. Uterine fibroid embolization unavoidably results in radiation exposure to the uterus and ovaries, and adherence to meticulous fluoroscopic technique is crucial to keep the absorbed dose as low as possible.

View details for PubMedID 12098105

Abstract

Conscious sedation and analgesia are integral components of successful uterine fibroid embolization (UFE), both in providing comfort to the anxious patient undergoing an elective procedure and for providing relief of the severe pelvic pain, cramps, and nausea that may result from acute uterine ischemia and the postembolization syndrome that may follow. The agents used are typically those with which interventional radiologists already have extensive experience in the performance of a variety of invasive procedures. Immediate postprocedure care benefits greatly from the use of narcotic delivered via PCA (patient-controlled analgesia) pump. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also particularly useful for treating the pain and cramping caused by UFE and help reduce the amount of narcotic necessary for pain relief during the recovery period. Detailed instructions for the first week of convalescence are necessary to insure comfort and avoid complications.

View details for PubMedID 12098106

Abstract

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

View details for PubMedID 12098104

Abstract

Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.

View details for PubMedID 12098109

Abstract

During endovascular abdominal aortic aneurysm (AAA) repair, larger aneurysms often present formidable anatomic challenges to the insertion of the delivery catheter and graft deployment. The authors sought to evaluate whether large-diameter aneurysms and those with short proximal aortic necks might be associated with a higher frequency of insertion-related and short-term complications.From October 1999 to August 2000, 144 patients underwent elective endovascular graft placement for infrarenal AAA disease at the authors' institution. These patients were treated with use of the AneuRx bifurcated endoprosthesis. AAA size (maximum aneurysm diameter) and proximal aortic neck length were compared to estimated blood loss, operative time, accuracy of graft placement, presence of endoleak, intraoperative and postoperative complications (such as limb occlusion or vascular injury), length of hospital stay, and mortality. Statistical methods included correlation analysis and logistic regression.There were 121 men and 23 women whose aneurysms ranged in size from 3 cm to 9.8 cm (mean, 5.6 cm; 95% CI, 5.4-5.8 cm). Endograft insertion was successful in all cases. There were three deaths within 30 days (2.1%) and seven deaths overall (4.9%). There were 43 intraoperative complications (29.9%) in 31 patients (21.5%), most of them minor. Patients with major intraoperative complications had significantly longer procedure times than those without complications (337 vs. 149 min; P <.0001). In the postoperative period (within 30 days), 31 complications (21.5%) occurred in 28 patients (19.4%), again most of them minor. AAA size was unrelated in any way to the rate of complications, but short proximal aortic neck length was associated with more serious intraoperative and postoperative complications (P =.0404 and P =.0230, respectively), and decreased 30-day and overall survival (P =.0240 and P =.0152, respectively).Endovascular repair of large AAAs can be challenging; however, the size of the AAA does not influence the rate of complications. A short proximal aortic neck is the only significant risk factor for more serious complications.

View details for Web of Science ID 000172724000002

View details for PubMedID 11742009

Abstract

As many as 39% of patients who undergo aortic endografting for abdominal aortic aneurysm disease will have ectasia of the iliac arteries that will require intervention. Coil embolization of the internal iliac artery and extension of the graft to the external iliac artery is one solution to this problem. However, 19%-41% of these patients experience buttock claudication, which may be permanent, after unilateral embolization. The authors examined an alternative: the use of larger-sized aortic cuffs to seal the iliac limb. Outcomes and short-term results are presented in this article.From October 1999 to August 2000, 144 AneuRx stent-grafts were placed at the authors' institution. Among the population receiving stent-grafts, 14 patients had 15 aortic cuffs placed across the distal iliac graft limbs to seal them and preserve flow to the internal iliac artery. One patient had bilateral cuffs placed. Five patients had embolization of the contralateral internal iliac artery because of bilateral disease. Patients were followed with computed tomography (CT) at 1, 6, and 12 months to evaluate for endoleaks.One- and 6-month endoleak rates, determined from only those patients with follow-up CT, were 0% and 10%, respectively. One type II endoleak was first discovered 9 months after graft placement. It sealed spontaneously at 15-month follow-up. One patient among the five who had internal iliac artery embolization had claudication. Mean CT follow-up was 7.8 months (range, 1-15). One patient declined CT but was alive and well 11 months after endografting. One patient moved across the country and declined follow-up.Placement of aortic cuffs in dilated iliac arteries can preserve flow to the ipsilateral internal iliac artery and provide an adequate seal. Additionally, the option of later treatment is maintained. Patients with bilateral iliac ectasia can undergo stent-graft placement without bilateral internal iliac artery embolization. Longer-term follow-up in larger numbers of patients will be important to determine the ultimate durability of this technique.

View details for Web of Science ID 000172724000003

View details for PubMedID 11742010

Abstract

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

View details for Web of Science ID 000171509900022

Abstract

To use angioscopy to evaluate and compare the amount of residual thrombus and endoluminal wall damage in hemodialysis grafts after percutaneous thrombectomy procedures.Thirty-nine thrombectomy and angioscopy procedures were performed in 35 patients. Percutaneous thrombectomy methods included eight different mechanical thrombectomy devices and the "lyse and wait" technique. Videotaped images of 33 angioscopic examinations were independently reviewed by three radiologists. Two parameters-the amount of residual thrombus and degree of endoluminal wall damage-were scored on a scale of 1 to 5. Data were initially analyzed to validate the grading system and then further studied to compare the different thrombectomy techniques.The Spearman rank order analysis validated the data pertaining to the amount of residual thrombus (r = 0.71, P < .0001), but there was poor correlation between reviewers regarding the degree of endoluminal wall damage. Combined scores from three reviewers revealed that the Cragg brush and Percutaneous Thrombectomy Device (PTD) left the smallest amounts of residual thrombus. The other methods tested, listed by increasing amount of residual thrombus, were the Endovac, Hydrolyser, Amplatz Thrombectomy Device, AngioJet, Oasis, and the lyse and wait technique. There were two complications related to angioscopy procedures.Subjective observations reveal that wall-contact thrombectomy devices leave less residual thrombus than hydrodynamic devices, aspiration devices, or the lyse and wait technique.

View details for Web of Science ID 000089200900004

View details for PubMedID 10997458

Abstract

To determine if scintigraphy with Tc-99m sulfur colloid can be used to detect perigraft flow after stent-graft repair of abdominal aortic aneurysm (AAA).Twenty-three men and two women aged 56-84 years (mean 71 years) underwent endoluminal AAA repair as part of the EVT Phase II trial [EVT = Endovascular Technologies (Menlo Park, CA, USA)]. Aneurysm size averaged 5.4 cm (range 3-8 cm). Sixteen bifurcated, seven tube, and two aorto-uniiliac grafts were placed. Two days after stent-graft placement, patients underwent both contrast-enhanced computed tomography (CT), including delayed views, and Tc-99m sulfur colloid scintigraphy.Perigraft flow was found in only one patient at completion of angiography. Four additional patients had perigraft flow, discovered during their postoperative follow-up CT. Four patients had leaks at an attachment site and one had retrograde branch flow. Tc-99m sulfur colloid scintigraphy failed to diagnose any of the five leaks prospectively. In two of these patients, however, some abnormal paraaortic activity was noted in retrospect.Tc-99m sulfur colloid scintigraphy was unable to demonstrate endoleak with either rapid flow (attachment site leak) or slow filling (branch flow).

View details for Web of Science ID 000083778500001

View details for PubMedID 10556401

View details for Web of Science ID 000083090700001

View details for PubMedID 10527189

Abstract

To evaluate patient perception of pain related to transrectal and transvaginal drainage and the catheter's effect on activities of daily living.From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4-80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1-10 and to rate the effect of the catheter on their activities of daily living.Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05).Of the transrectal and transvaginal approaches, transrectal is better tolerated.

View details for Web of Science ID 000081086900025

View details for PubMedID 10405736

Abstract

To compare the efficacy of open and laparoscopic lymphadenectomy and validate an objective model of lymph node retrieval using lymphangiography in pigs.Twenty-five pigs weighing 54-75 lbs were randomly assigned by side to open or laparoscopic pelvic and paraaortic lymphadenectomy. Lymph node yield, quantified by a masked pathologist, operative time, complications, blood loss, and other variables were recorded. Lymphangiography was done, and radiographs were taken before and after lymph node harvesting. Statistical analysis used McNemar test for nominal data and paired Student t test or Wilcoxon signed-rank test for continuous variables.Lymph node yields were a mean of 11.5 with a standard deviation of 2.8 for open and 15.3 +/- 3.4 nodes for laparoscopic lymphadenectomy (P = .009). Mean operating time was 26.5 +/- 5.3 minutes for open versus 54.9 +/- 23.7 minutes for laparoscopy (P < .01). Mean blood loss was higher for laparoscopic cases, 35 mL for open versus 58 mL for laparoscopic lymphadenectomy (P = .048). The four major complications were evenly distributed between the two procedures. Lymphangiography was successful in 24 of 25 pigs. A total of 243 lymph nodes were identified with equal distribution by side. Lymphangiographic data correlated well with number of lymph nodes retrieved.In this randomized trial, laparoscopic lymphadenectomy was at least as effective as open lymphadenectomy, although operating time and blood loss were greater. Lymphangiography was a reliable, objective mode for documentation and assurance of lymph node recovery.

View details for Web of Science ID 000079313100026

View details for PubMedID 10214842

Abstract

To recanalize the endocervical canal in a patient with partial congenital cervical atresia.Case report.University hospital.A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract.At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively.Hysterosalpingography and clinical follow-up.The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date).In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

View details for Web of Science ID 000078065500030

View details for PubMedID 9935135

Abstract

This report details our initial experience with two types of endovascular grafts- one for the treatment of infrarenal abdominal aortic aneurysms and the other for the treatment of iliac artery occlusive disease.An abdominal aortic aneurysm was repaired in 34 patients using 3 different types of Ancure endografts (Menlo Park, California). Control patients (n = 9) had a standard aneurysm repair. Patients with chronic lower extremity ischemia (n = 7) secondary to iliac artery occlusive disease were treated with a Hemobahn endograft (W. L. Gore & Associates, Flagstaff, Arizona).Ancure graft deployment was achieved in 33 of 34 (97.1%) patients. Perioperative mortality for the Ancure and control group patients was 2.9% and 0%, respectively. Periprosthetic leaks were identified within 48 hours of deployment in 6 (18.2%) Ancure graft patients. All but 2 of the leaks resolved on serial follow-up. Additional endovascular procedures were required in 11 (32.4%) Ancure graft patients at the initial procedure or during follow-up to correct graft or arterial stenoses. Patients treated with an endovascular graft had significantly less blood loss and shorter hospital stays than control group patients. For Hemobahn patients, the technical success for graft deployment was 100%. There were no perioperative deaths. The ankle/brachial index increased from a mean of 0.52 preoperatively to 0.86 postoperatively (P = 0.004). One patient required a Wallstent in follow-up to correct a graft wrinkle. Angiography at 6 months demonstrated mild intimal hyperplasia in the stent graft in 5 of 6 patients.These early results support the potential for endovascular grafts in the treatment of aneurysmal and occlusive vascular disease. Further modifications in the devices and deployment techniques are necessary to reduce the incidence of periprosthetic leaks, graft limb stenoses, and intimal hyperplasia.

View details for Web of Science ID 000078160800048

View details for PubMedID 9926793

Abstract

To examine the efficacy of transperineal sonographically guided drainage of deep pelvic abscesses.Twelve drainage procedures were performed in 11 adults with symptoms of infection and cross-sectional images demonstrating a deep pelvic abscess. Eight patients had recently undergone abdominoperineal resection, seven of whom underwent preoperative radiation therapy. Two had chronic osteomyelitis with adjacent fluid collections, and one developed an infected hematoma after trauma. With ultrasound (US) guidance for initial access, catheters were placed for drainage in 11 procedures. One patient was treated with aspiration alone. Patients underwent clinical follow-up and subsequent imaging as necessary.Transperineal needle placement was successful in 12 of 12 patients (100%). In procedures that required catheter placement, 10 of 11 placements (91%) were achieved with the transperineal approach. One patient required fluoroscopic transvaginal catheter placement after opacification of the collection transperineally. Catheter drainage was maintained for 2-146 days (mean, 40 days; median, 21 days). Clinical success was achieved in nine of 10 patients (90%) by means of transperineal drainage. There were no complications, although premature catheter removal occurred in two patients.US-guided transperineal abscess drainage may be successfully performed in patients who cannot undergo conventional transabdominal, transvaginal, or transrectal catheter drainage.

View details for Web of Science ID 000074296300018

View details for PubMedID 9646800

View details for Web of Science ID A1997XW31800007

View details for PubMedID 9314369

Abstract

To determine the effectiveness of using Wallstents to treat subclavian or brachiocephalic venous obstruction after unsuccessful angioplasty, in patients undergoing hemodialysis.Dialysis records, radiology reports, and procedural images of 20 hemodialysis patients who underwent Wallstent insertion into a subclavian (n = 11) or brachiocephalic (n = 9) vein were reviewed. Technical success and primary, assisted primary, and cumulative patency rates were calculated.Twenty-three Wallstents were inserted for stenosis (n = 18) or occlusion (n = 2). Technical success was 100%. Eight patients underwent 11 reinterventions to maintain patency of the Wallstent during the follow-up period. Patency rates of the Wallstent were (a) primary at 1 month, 3 months, 6 months, and 1 year: 90%, 67%, 42%, and 25%; (b) assisted primary at 3 months, 6 months, and 1 year: 88%, 62%, and 47%; and (c) cumulative at 3 months, 6 months, 1 year, and 2 years: 89%, 64%, 56%, and 22%. Considerable shortening of the stent occurred in five patients. One occurred immediately during the deployment procedure, but four were discovered weeks to months later. No other complications occurred.After suboptimal angioplasty, treatment of subclavian and brachiocephalic vein stenoses with a Wallstent can provide continued use of a hemodialysis access. Close clinical surveillance and multiple reinterventions are necessary to maintain Wallstent patency.

View details for Web of Science ID A1997XL64400011

View details for PubMedID 9240518

Abstract

The TR and TV approaches to deep pelvic abscesses have been made safe and easy by improvements in endoluminal US technology. Most procedures take well under an hour, and standard intravenous sedation is usually sufficient for patient comfort. The simplest and safest technique employs a combination of endoluminal US, with biopsy guides for precision needle advancement, and fluoroscopy for dilating the tract and placing a drainage catheter. Patient acceptance of TR and TV catheters is high, and resolution can typically be expected within 3-5 days. In the majority of cases, catheter treatment, combined with antibiotic therapy, is curative.

View details for Web of Science ID A1997XK42500003

View details for PubMedID 9232564

Abstract

The authors developed a porcine model for direct lymphangiography to be used as a reference for lymph node harvesting.A pilot animal was studied first to develop the protocol, which was used successfully in 24 pigs. An indicator dye was first injected into each foot to make the lymphatic vessels visible. Then, ethiodized poppy seed oil was injected directly through cutdowns in both groins. Radiographs were obtained before and after lymph node harvesting.Images were of diagnostic quality in all animals. The pilot animal developed transient respiratory distress, which was thought to be due to the oil-based contrast material. The amount injected was reduced by half, and no episodes occurred thereafter in the study group. There were no other immediate or delayed complications.Direct lymphangiography is safe, easy, and reliable in a porcine model.

View details for Web of Science ID A1997WY03500006

View details for PubMedID 9156233

Abstract

To review the technical results and long-term follow-up of the first 157 consecutive patients undergoing placement of 161 chest wall ports at the authors' institution.All ports were placed in the interventional radiology suite with use of fluoroscopic and/or ultrasound guidance with a combination of standard interventional radiology and surgical techniques. The hospital records of all patients were reviewed, and telephone contact made when possible. Patients ranged in age from 21 to 87 years (average, 57 years). The most common indication for port placement was chemotherapy (88%).Placement was technically successful in all 161 procedures. Minor procedural complications occurred in eight patients (5%). There were no major complications related to the procedure. Cumulative follow-up to date includes 35,992 port-days (average, 226 days per patient). The long-term complication rate was 8.7% or .39 per 1,000 access days, which includes nine infections and five migration-related complications.Interventional radiologic placement of chest wall ports is safe and has a high technical success rate, in large part due to the integration of interventional radiology techniques to the procedure. The short and long-term complication rates are equal to or less than those of current surgical series.

View details for Web of Science ID A1997WP05100004

View details for PubMedID 9083981

View details for Web of Science ID A1996VP38900060

View details for PubMedID 8888268

Abstract

To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents.Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy.Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months).Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

View details for Web of Science ID A1996VD06200025

View details for PubMedID 8756921

View details for Web of Science ID A1996VB73500020

View details for PubMedID 8855540

Abstract

To evaluate gallstone and symptom recurrence rates, long-term complications, and life expectancy after percutaneous gallstone removal.Medical records of 87 patients (mean age, 69 years +/- 14 [standard deviation]) undergoing percutaneous gallstone removal between 1987 and 1992 were reviewed. Physicians and patients (or their families) were contacted for clinical follow-up. Thirty-one patients returned for follow-up ultrasound (US).The final study group consisted of 65 patients. Mean survival from the time of initial gallbladder drainage was 33 months +/- 19. Over a mean clinical follow-up period of 33 months, eight of 65 patients (12%) developed recurrent symptoms; six of these eight had recurrent gallstones shown at US. Of 30 patients with technically adequate US images (mean follow-up, 14 months +/- 12), 12 (40%) had recurrent gallstones. Six of these 12 patients had recurrent symptoms. No long-term complications were identified.The risk of gallstone recurrence after percutaneous removal is notable, but the symptom recurrence rate is much lower. Percutaneous gallstone removal is beneficial for patients at prohibitive surgical or general anesthetic risk.

View details for Web of Science ID A1996UQ43800010

View details for PubMedID 9007802

View details for Web of Science ID A1996TM68000005

View details for PubMedID 8539367

Abstract

To evaluate the accuracy of intraarterial digital subtraction angiography (DSA) in the demonstration of patent infrapopliteal vessels.One-hundred sixty-five arteriograms were obtained in 153 consecutive patients prospectively enrolled to evaluate lower extremity ischemia. In 86 cases a follow-up angiogram of the infrapopliteal vessels was obtained during surgery or after endovascular intervention (n = 57). Twenty-nine arteriograms were followed by surgical exploration of the infrapopliteal vessels. Standard angiographic technique was performed with intraarterial DSA of the most symptomatic foot. Visualization of distal vessels was compared with intraoperative or postintervention imaging or with the results of surgical exploration.Of the 57 procedures after which either intraoperative or post-endovascular intervention angiography was performed, DSA results were equivalent in 47 (82%) and worse in five (9%). When individual vessels were evaluated, the sensitivity of DSA in the identification of patent named vessels was 95%, and the specificity was 92%. Among 29 cases with a surgical standard of reference, 28 patients underwent bypass to a vessel correctly identified as patent at DSA; one patient was incorrectly identified as having no patent named vessels.Intraarterial DSA is accurate and reliable in the assessment of patency in infrapopliteal vessels before surgery or endovascular intervention in patients with infrainguinal atherosclerotic disease.

View details for Web of Science ID A1995RP01400021

View details for PubMedID 7579870

Abstract

We report a renal transplantation with uretero-ureterostomy to a normal ureter in a patient with VATER syndrome who had agenesis of the ipsilateral kidney. Anomalous insertion of the native ureter into the ejeculatory duct was subsequently identified when his post-operative course was complicated by an ureteric leak and hydronephrosis. To our knowledge, this anomaly has not been previously reported. Transplant function is now excellent following temporary percutaneous nephrostomy. Contrast delineation of genito-urinary anatomy is recommended, before utilizing existing anatomical structures in the urinary tract, in patients with VATER syndrome.

View details for Web of Science ID A1995QV67600011

View details for PubMedID 7599401

Abstract

The purpose of this study was to evaluate the clinical efficacy of transvaginal sonographically guided aspiration and drainage of pelvic fluid collections.Forty patients underwent transvaginal sonographically guided aspiration of a possible pelvic abscess (41 pelvic collections). In patients with clinical findings highly suggestive of infection, both purulent and nonpurulent collections were immediately drained via a catheter. In patients with clinical findings moderately suggestive of infection, nonpurulent collections were completely removed by aspiration and the aspirates were cultured; however, purulent collections were immediately drained via a catheter.All collections were successfully accessed by transvaginal sonography. For 27 of the 41 collections, the aspirate was purulent (18 collections) or the patient's clinical findings were highly suggestive of infection (nine collections) and catheter drainage was performed. Seventeen of the 27 collections completely resolved and surgery was not required. Four of the 27 collections were in patients who had surgery for reasons other than persistent infected collection. For six of the 27 collections, catheter treatment was not successful and surgery was required. The overall success rate of catheter drainage was 78%. In the remaining 14 of the 41 collections, the aspirate was serous or serosanguineous, and the patient's clinical findings were moderately suggestive of infection. Cultures of aspirates of seven collections were positive for microorganisms. Eleven collections were successfully treated with antibiotics or no therapy was required (based on culture results); for three, surgery was required. Two complications occurred: one vaginal fistula after catheter drainage and one disruption of vaginal sutures after aspiration.Transvaginal sonographically guided drainage is effective treatment of pelvic abscess, being either completely curative or temporizing in 78% of patients. Catheter treatment was unsuccessful and surgery was necessary in 22% of patients. For nonpurulent collections, catheter drainage is indicated only when clinical findings are highly suggestive of infection.

View details for Web of Science ID A1994PQ81700022

View details for PubMedID 7976890

Abstract

To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition.From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure.Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy.Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.

View details for Web of Science ID A1994MW25300028

View details for PubMedID 8259391

View details for PubMedID 8281003

View details for Web of Science ID A1992JE56700059

View details for PubMedID 1632380

Abstract

In order to assess the ability of magnetic resonance (MR) imaging to distinguish simple renal cysts from renal tumors, images from 53 patients with 74 lesions were reviewed. MR image characteristics, including signal strength and homogeneity for each lesion, were evaluated and compared with the final diagnoses. There were 53 cysts and 21 tumors. For 56 lesions (76%), MR allowed accurate diagnosis; on T1-weighted images, homogeneous low-intensity lesions were always cysts and inhomogeneous medium- or high-intensity lesions were always tumors. The remaining 18 lesions (24%) could not be distinguished, and T2-weighted images failed to improve differential diagnostic ability. In our experience, MR imaging allows differentiation of renal cysts and tumors less frequently than does computed tomography (CT) or ultrasound (US). MR criteria for simple renal cysts and tumors are offered, with the understanding that modification may be necessary as experience with these lesions increases.

View details for Web of Science ID A1990EA90100002

View details for PubMedID 2238286

Abstract

This article provides an atlas of penile prosthetic implants currently in use. It is believed that an understanding of the structure and mechanism of these prostheses is essential to an accurate radiologic assessment of their integrity and to the recognition of the cause in cases of malfunction.

View details for PubMedID 2756193

View details for Web of Science ID A1986D905300057

View details for PubMedID 3740701

Abstract

The human serum protein, haptoglobin, forms a stable, irreversible complex with hemoglobin. Haptoglobin is composed of two H chains, which are connected via two smaller L chains to give a protein of 85,000 Mr. In the complex, each H chain binds an alpha beta dimer of hemoglobin for a total molecular weight of 150,000. The scanning transmission electron microscope has been used to derive new information about the shape and structure of haptoglobin and hemoglobin, and about their relative orientation in the complex. The micrographs of negatively stained images show that haptoglobin has the shape of a barbell with two spherical head groups, which are the H chains. These are connected by a thin filament with a central knob, which corresponds to the L chains. The overall length of the molecule is about 124(+/- 8) A and the interhead distance is 87 (+/- 7) A. In the haptoglobin-hemoglobin complex, the head groups are ellipsoidal and under optimal staining conditions bilobal . Thus, the alpha beta dimers are binding to the H chains, but off the long axis of the barbell by 127 degrees in a trans configuration. This angle considerably restricts the region on the surface of the H chain structure that can contain the hemoglobin binding site. The interhead group distance for complex is 116.5(+/- 6.3) A or 30 A greater than for haptoglobin. The N terminus of the beta chain was located on the trans off-axis configured barbell structure of complex by using a hemoglobin that was crosslinked between the alpha beta dimers in the region of the beta N terminus. The distances and angles that are measured on the micrographs for the native and crosslinked complex molecules permit the directions of two of the alpha beta dimer ellipsoid axes to be assigned. Taken together, these data provide an approximate relative orientation for the binding of the alpha beta dimer to the H chain of haptoglobin.

View details for Web of Science ID A1984SN18200005

View details for PubMedID 6716481

Abstract

Haptoglobin (Hp) consists of light (L) and heavy (H) chains, the latter of which combine with hemoglobin alpha beta dimers to form a highly stable complex. Human haptoglobin assembles as HL units that occur in two allelic forms; HL1 , which is monovalent, and HL2 , which is divalent. As a result, three phenotypic forms exist in the human population: Hp1-1, the homozygous form in which the monovalent HL1 unit occurs as a dimer; Hp2-2, the homozygous form of the divalent HL2 unit, which gives a series of polymers; and the heterozygous Hp2-1 form, which gives a different series of polymers. We have investigated the structures and assembly properties of these two haptoglobin polymeric series in their complexes with hemoglobin using high-resolution scanning transmission electron microscopy. Polymers of complex are composed of ellipsoidal or bilobal head groups, which are the H alpha beta subunits connected by thin filament-like structures, which are the L chains. Polymers of size up to pentamers can be identified easily by counting the number of head groups in the molecule. Complex 2-1 and complex 2-2 trimers were studied extensively. The differences in detailed morphology show that while the 2-1 trimer is a linear polymer, the 2-2 trimer is a closed circular molecule. The micrograph images suggest that complex 2-2 tetramers and pentamers, and perhaps higher forms may also be cyclic. The structure of the L2 subunit of haptoglobin is shown to be composed of two domains, which may be similar in structure to the single domain of the monovalent L1 chain. The two L2 domains are connected by a hinge that has quite limited flexibility. Using these structural models, assembly characteristics and structural properties of the trimers and tetramers of complex 2-1 and complex 2-2 are described.

View details for Web of Science ID A1984SN18200006

View details for PubMedID 6716482