Adnan Hadziomerovic

Spherical versus Conventional Polyvinyl Alcohol Particles for Uterine Artery Embolization

PURPOSE To compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE). MATERIALS AND METHODS Of 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure. RESULTS On 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations. CONCLUSIONS In comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

Randomized Trial Comparing the Primary Patency following Cutting Versus High-Pressure Balloon Angioplasty for Treatment of de Novo Venous Stenoses in Hemodialysis Arteriovenous Fistulae

PURPOSE A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arteriovenous (AV) fistulae for hemodialysis. MATERIALS AND METHODS Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty with a cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 mm are not available. Nine patients were excluded after angiography, with seven requiring balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference, 9 y; P = .04), but other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo). Kaplan-Meier analysis was used to compare duration of patency. Mann-Whitney rank-sum t test and χ2/Fisher exact tests were used to compare continuous and categoric variables, respectively. RESULTS Technical success was achieved in all 39 patients. At 3, 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI], 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%), 42.1% (95% CI, 20.25%-66.50%), and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval). CONCLUSIONS Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

Renal Sympathetic Denervation for Resistant Hypertension

Resistant hypertension is an increasingly prevalent health problem associated with important adverse cardiovascular outcomes. The pathophysiology that underlies this condition involves increased function of both the sympathetic nervous system and the renin-angiotensin II-aldosterone system. A crucial link between these 2 systems is the web of sympathetic fibres that course within the adventitia of the renal arteries. These nerves can be targeted by applying radiofrequency energy from the lumen of the renal arteries to renal artery walls (percutaneous renal sympathetic denervation [RSD]), an approach that has attracted great interest. This paper critically reviews the evidence supporting the use of RSD. Small studies suggest that RSD can produce dramatic blood pressure reductions: In the randomized Symplicity HTN-2 trial of 106 patients, the mean fall in blood pressure at 6 months in patients who received the treatment was 32/12 mm Hg. However, there are limitations to the evidence for RSD in the treatment of resistant hypertension. These include the small number of patients studied; the lack of any placebo-controlled evidence; the fact that blood pressure outcomes were based on office assessments, as opposed to 24-hour ambulatory monitoring; the lack of longer-term efficacy data; and the lack of long-term safety data. Some of these concerns are being addressed in the ongoing Renal Denervation in Patients With Uncontrolled Hypertension (Symplicity HTN-3) trial. The first percutaneous RSD system was approved by Health Canada in the spring of 2012. But until more and better-quality data are available, this procedure should generally be reserved for those patients whose resistant hypertension is truly uncontrolled.

Percutaneous Renal Sympathetic Denervation: 2013 and Beyond

Systemic hypertension affects almost a quarter of Canadian adults. Although most can achieve adequate blood pressure control using a combination of medical and lifestyle interventions, many have resistant hypertension and are unable to reach their target. Percutaneous renal sympathetic denervation has been developed to address a crucial mechanism in the pathophysiology of hypertension: renal sympathetic overactivity. In 2009, the first-in-man experience with renal denervation was published. Several studies followed, including the randomized Symplicity HTN-2 trial of 106 patients: 6-month mean blood pressure reduction was 32/12 mm Hg in those who underwent renal denervation, vs a change of +1/0 Hg in those who did not. However, all the evidence to date suffers from the same drawbacks: studies are small, and follow-up is short and largely incomplete. The future of renal denervation will be determined by 3 factors. First, there will be more and better evidence. Symplicity HTN-3 has randomized 530 patients to renal denervation vs a sham procedure; 24-hour ambulatory blood pressure monitoring will be assessed in all participants. Other quality trials will follow, including ones that will assess clinical end points. Second, other indications for this treatment will be investigated. Sympathetic overactivity is implicated in many other conditions, including heart failure and arrhythmia; sympathetic denervation might benefit these patients as well. Third, myriad devices, using different methods to achieve renal denervation, are being developed. The first renal denervation system was approved for clinical use in Canada in March 2012. Until more data are available, patients undergoing this procedure should be carefully screened and, ideally, enrolled in research protocols.

Embolotherapy of a dieulafoy lesion in the cecum: case report and review of the literature.

JVIR 2000; 11:1059–1062 DIEULAFOY lesion is an uncommon cause of massive gastrointestinal hemorrhage. Bleeding occurs through a mucosal erosion from an abnormally dilated submucosal artery. Dieulafoy lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract (1–7). Both endoscopy and angiography have been used for the diagnosis of Dieulafoy lesion (3,4,6–8). Treatment of Dieulafoy lesion has been primarily surgical, but endoscopic coagulation, sclerotherapy, and band ligation are now becoming standard treatments (1,4,8–10). We describe a patient with a Dieulafoy lesion in the cecum that was treated with transcatheter arterial embolization.

Endoluminal dilatation for embedded hemodialysis catheters: A case-control study of factors associated with embedding and clinical outcomes

Background With the increasing frequency of tunneled hemodialysis catheter use there is a parallel increase in the need for removal and/or exchange. A small but significant minority of catheters become embedded or ‘stuck’ and cannot be removed by traditional means. Management of embedded catheters involves cutting the catheter, burying the retained fragment with a subsequent increased risk of infections and thrombosis. Endoluminal dilatation may provide a potential safe and effective technique for removing embedded catheters, however, to date, there is a paucity of data. Objectives 1) To determine factors associated with catheters becoming embedded and 2) to determine outcomes associated with endoluminal dilatation Methods All patients with endoluminal dilatation for embedded catheters at our institution since Jan. 2010 were included. Patients who had an embedded catheter were matched 1:3 with patients with uncomplicated catheter removal. Baseline patient and catheter characteristics were compared. Outcomes included procedural success and procedure-related infection. Logistic regression models were used to determine factors associated with embedded catheters. Results We matched 15 cases of embedded tunneled catheters with 45 controls. Among patients with embedded catheters, there were no complications with endoluminal dilatation. Factors independently associated with embedded catheters included catheter dwell time (> 2 years) and history of central venous stenosis. Conclusion Embedded catheters can be successfully managed by endoluminal dilatation with minimal complications and factors associated with embedding include dwell times > 2 years and/or with a history of central venous stenosis.

Modified Inside-Out Technique for Continued Use of Chronically Occluded Upper Central Veins

This report describes a 2-step, inside-out procedure for upper body central venous access in patients with chronic central venous occlusions. Blunt cephalad dissection through the mediastinum was achieved with a curved metal cannula and guide wire followed by percutaneous puncture of an open snare from a right supraclavicular approach and dilation of the tract for a tunneled central venous catheter insertion. Of 9 patients, all had a successful placement of a tunneled central venous catheter using this method. Although this 2-step, inside-out technique is effective for creating access in the presence of central venous occlusion, further clinical evaluation is warranted.

Infolding of fenestrated endovascular stent graft

We report a case of infolding of a fenestrated stent graft involving the visceral vessel segment after a juxtarenal abdominal aorta aneurysm repair. The patient remains free of any significant endoleak, and the aortic sac has shown regression. The patient remains asymptomatic, with no abdominal pain, with normal renal function, and without ischemic limb complications. We hypothesize that significant graft oversizing (20%-30%) with asymmetric engineering of the diameter-reducing ties may have contributed to the infolding. Because of the patients asymptomatic nature and general medical comorbidities, further intervention was deemed inappropriate as the aneurysmal sac is regressing despite the infolding.

The Ottawa Hospital RADiologist Activity Reporting (RADAR) Productivity Metric: Effects on Radiologist Productivity

Productivity is challenging to measure in a complex the Ottawa RADAR score reflects our department’s own radiology organization. This is particularly true in an academic department where radiologists have a broad portfolio of scholarship and obligations, including clinical service, education, administration, and research. We developed the Ottawa RADiologist Activity Reporting (RADAR) score, which is a radiologist productivity measurement system designed to recognize both clinical and academic productivity and to express that productivity with a simple metric. This was implemented in our Canadian, academic radiology department with wide-ranging, complex clinical work; large teaching programs including residents and fellows; dedicated research time; and administrative tasks. In this article, we report data analysis of how implementation of the RADAR score affected radiologist productivity.

Externalization of Tunneled Hemodialysis Catheter in Patients with Tunnel or Exit-Site Infections and Limited Access Options

PURPOSE To evaluate the viability and effectiveness of temporary externalization of a tunneled hemodialysis (HD) catheter in catheter-dependent HD patients presenting with catheter-related tunnel or exit-site infection, documented central venous stenosis, and limited alternative venous access. MATERIALS AND METHODS All catheter-dependent HD patients with known central venous stenosis presenting with exit-site or tunnel infection and who subsequently underwent catheter externalization between February 2008 and May 2012 were reviewed. After catheter externalization, patients were concurrently treated with antibiotics for approximately 3 weeks before reinsertion of a new tunneled catheter. Treatment outcomes were collected, with treatment failures defined as reinfection with the same organism within 45 days of tunneled catheter reinsertion. RESULTS There were 42 catheter externalization procedures performed in 26 patients for 42 exit-site or tunnel infections. Technical success rate for catheter externalization was 100%, with no complications during the externalization procedure and preservation of all original access sites. Treatment failure occurred in 9.8% (4 of 41) of cases. Median infection-free survival after treatment and retunneling of a new dialysis catheter was 80 days. One major periprocedural complication of death occurred before reinsertion of a new tunneled catheter. Minor complications after the procedure occurred in four patients and included three cases of a small persistent wound at the temporary supraclavicular access site and one initially nonfunctioning externalized catheter. CONCLUSIONS Temporary dialysis catheter externalization appears both technically feasible and effective for the treatment of exit-site and tunnel infections, while allowing preservation of the venous access site in catheter-dependent HD patients with central venous stenosis and limited alternative venous access.