C. Fan

Uterine Artery Embolization in the Treatment of Postpartum Uterine Hemorrhage

PURPOSEnTo evaluate the clinical effectiveness and safety of uterine artery embolization (UAE) in the treatment of primary postpartum hemorrhage (PPH), secondary PPH, and PPH associated with cesarean section.nnnMATERIALS AND METHODSnAll women who underwent UAE for obstetric-related hemorrhage during a 52-month period culminating in April 2009 were included. Clinical success was defined as obviation of hysterectomy. Blood product requirements before and after UAE were calculated. Statistically significant associations between subject characteristics and clinical success were evaluated. The two subgroups of women with uterine artery pseudoaneurysms and women who underwent cesarean section were examined separately as well.nnnRESULTSnSixty-six women (mean age, 33 years; range, 17-47 y) underwent UAE, with an overall clinical success rate of 95% (98% for primary PPH, 88% for secondary PPH, and 94% for PPH associated with cesarean section) and an overall complication rate of 4.5%. Mean pre- and postembolization transfusion requirements were 3.1 U and 0.4 U of packed red blood cells, respectively. The only significant characteristic identified for the cases that necessitated hysterectomy was an increased transfusion requirement after UAE (increase of 1.0 U ± 0.5; P = .02). Uterine artery pseudoaneurysms were associated with secondary PPH (P = .01) and cesarean section (P = .03).nnnCONCLUSIONSnThe threshold for UAE in women with PPH should be low, as it is associated with a high clinical effectiveness rate and a low complication rate. Uterine artery pseudoaneurysms should be suspected in women presenting with secondary PPH after cesarean section.

Thoracic Duct Embolization and Disruption for Treatment of Chylous Effusions: Experience with 105 Patients

PURPOSEnTo review the indications, technical approach, and clinical outcomes of thoracic duct embolization (TDE) and thoracic duct disruption (TDD) in patients with symptomatic chylous effusions.nnnMATERIALS AND METHODSnA total of 105 patients who underwent 120 consecutive TDE/TDD procedures were retrospectively reviewed. Data including cause of effusion, procedural technique, and pre- and postprocedural effusion volume were analyzed. Technical and clinical success were evaluated for each procedure, with technical success defined as successful interruption of the thoracic duct by embolization or needle disruption and clinical success defined as resolution of effusion without surgical intervention.nnnRESULTSnThe technical success rate was 79% (95 of 120); 53 TDEs were performed, resulting in a 72% clinical success rate (n = 38), whereas 42 TDDs showed a 55% clinical success rate (n = 23; P = .13). Procedures to treat postpneumonectomy chylous effusions had a success rate of 82% (14 of 17), compared with 47% (nine of 19) in postpleurectomy subjects (P < .05). Clinically successful cases had lower 24-, 48-, and 72-hour postprocedural effusion volumes versus clinically unsuccessful cases (P < .05), as well as greater rates of reduction in effusion volume at these time points (P < .05). Clinical success rate in subjects with traumatic effusions was higher than in subjects with nontraumatic effusions (62% [60 of 97] vs 13% [one of eight]; P < .05), and 6.7% of subjects (n = 7) experienced minor complications.nnnCONCLUSIONSnTDE and TDD are safe and effective minimally invasive treatments for traumatic thoracic duct injuries. In the present series, factors affecting procedural success included etiology of effusion, postprocedural effusion volume, and rate of postprocedural effusion volume reduction.

Safety and Utility of Transjugular Liver Biopsy in Hematopoietic Stem Cell Transplant Recipients

PURPOSEnHematopoietic stem cell transplant (HSCT) recipients are at high risk in the setting of percutaneous liver biopsy as a result of comorbid coagulopathy and ascites, and are commonly referred to undergo transjugular liver biopsy. The present study was performed to assess the safety and utility of transjugular liver biopsy in HSCT recipients and to analyze the correlation between corrected hepatic sinusoidal pressure gradient (CHSPG) and pathologic diagnoses.nnnMATERIALS AND METHODSnData from reports of transjugular liver biopsy procedures, pathology reports, and laboratory values of 141 consecutive HSCT recipients who underwent transjugular liver biopsy with pressure measurement between January 2005 and August 2011 in a single institution were retrospectively reviewed and analyzed.nnnRESULTSnA total of 166 biopsy procedures were performed in 141 patients. Technical success rate was 98.8%. Biopsy was diagnostic in 95.7% of patients. There were three major complications (1.8%), including one death. CHSPG in patients with venoocclusive disease (VOD) was significantly higher (P<.001) than in those without VOD (16.2 mm Hg±9.2 vs 5.6 mm Hg±3.7). A CHSPG of 10 mm Hg or higher was 90.8% specific and 77.3% sensitive for VOD.nnnCONCLUSIONSnThe present data show that transjugular liver biopsy is a relatively safe procedure that provides important information for the clinical management of patients with HSCT. Measurement of CHSPG during the procedure can support the diagnosis of VOD.

Lymphangiography for Thoracic Duct Interventions

Lymph leaks resulting in chylous pleural effusions can be life-threatening. Minimally invasive thoracic duct embolization and disruption have been gaining acceptance as first-line treatment for these leaks. This review discusses the techniques for both pedal and intranodal lymphangiography in detail. It also discusses the use of lymphangiography as a means of targeting a retroperitoneal lymphatic to facilitate thoracic duct interventions for chyle leaks. Finally, outcomes and adverse events pertaining to these thoracic duct interventions are discussed.