Eric Dorenberg

Recurrent rupture of a hypogastric aneurysm caused by spontaneous recanalization of an Amplatzer vascular plug.

A patient with a ruptured hypogastric aneurysm was treated via an endovascular approach with coils in the outflow vessels and an Amplatzer vascular plug (AVP) in the main trunk. After 4 weeks, the patient was readmitted with a recurrence of rupture of the hypogastric aneurysm caused by recanalization of the AVP. Final occlusion of the hypogastric artery was achieved by placement of a stent-graft and additional coils. In consideration of this experience, it is recommended that additional coils or several AVPs be used and early contrast medium-enhanced computed tomography follow-up be performed.

Volumetric ablation of uterine fibroids using Sonalleve high-intensity focused ultrasound in a 3 Tesla scanner – first clinical assessment

Abstract Introduction: The purpose of this study was to evaluate the feasibility and safety of the Sonalleve high-intensity focused ultrasound (HIFU; Philips Healthcare, Vantaa, Finland) system in ablating uterine fibroids in a 3T magnet. Material and methods: Seven women were included in this study. Treatment was performed according to the manufacturers recommendation. Technical data describing the HIFU procedures were collected. On MR images at baseline, immediately and 30 days after ablation, we evaluated the volumes of the uterus, the dominant fibroid and the ablation zone. The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire was used to assess potential clinical response. Results: The procedure was technically feasible in all patients. The median number of sonications performed during each procedure was 20 (range 2–27) per patient, the maximum temperature in all sonication cells was about 68°C. The median procedure time was 156 minutes (range 95–164). The non-perfused volume after treatment ranged from 1 to 27 ml and was unchanged or decreased in all but one patient at 30 days follow-up. There were no major adverse events. Discussion: In our 3T magnet the system was able to heat tissue and induce areas of non-enhancement within uterine fibroids without major complications. Clinical benefit remains to be proven.

Uterine fibroid embolization can still be improved: observations on post-procedure magnetic resonance imaging

Purpose: To evaluate the efficacy and completeness of uterine fibroid embolization (UFE) measured by changes in volume and signal intensity at magnetic resonance imaging (MRI), and to compare with clinical outcome. Material and Methods: 40 women with symptomatic uterine fibroids underwent bilateral uterine artery embolization. At MRI studies, including post-contrast sequences before and repeatedly after treatment, the uterus and dominant fibroids were evaluated for volume, location, and contrast enhancement. Prior to treatment, all myomas showed significant contrast enhancement. The mean uterine volume was 929 ml. Clinical examinations with emphasis on menorrhagia, pelvic pain, and urinary dysfunction were performed before and 6 and 12 months after treatment. Results: UFE was bilaterally successful in 38 patients. After UFE, MRI showed no enhancement of myomas in 30 patients. In 8 patients, post-procedural MRI revealed partially remaining vascularization of fibroids despite angiographically complete embolization of the uterine arteries. On average, uterine volume decreased by 46.2% at 12 months. There was significant improvement of symptoms in the majority of patients, but slightly less improvement in patients with partially remaining vascularization of myomas. Conclusion: UFE causes significant volume reduction of myomas and clinical improvement. MRI can reveal remaining vascularization in myomas despite angiographically complete embolization of uterine arteries.

The Feasibility of Contrast-Enhanced Ultrasound During Uterine Artery Embolization: A Pilot Study

PurposeTo evaluate the feasibility of using contrast-enhanced ultrasound (CEUS) during uterine artery embolization (UAE) in order to define the correct end-point of embolization with complete devascularization of all fibroids.MethodsIn this prospective study of 10 consecutive women undergoing UAE, CEUS was performed in the angiographic suite during embolization. When the angiographic end-point, defined as the “pruned-tree” appearance of the uterine arteries was reached, CEUS was performed while the angiographic catheters to both uterine arteries were kept in place. The decision whether or not to continue the embolization was based on the findings at CEUS. The results of CEUS were compared with those of contrast-enhanced magnetic resonance imaging (MRI) 1 day as well as 3 months following UAE.ResultsCEUS was successfully performed in all women. In 4 cases injection of particles was continued based on the findings at CEUS despite angiographically complete embolization. CEUS imaging at completion of UAE correlated well with the findings at MRI.ConclusionThe use of CEUS during UAE is feasible and may increase the quality of UAE.

Fourteen-year-old boy with severe hypertension and monosymptomatic nocturnal enuresis (Discussion and Diagnosis)

DISCUSSION Most cases of confirmed childhood hypertension are secondary to other diseases and are renal in origin (1). Renovascular disease causes 5–10% of all childhood hypertension, with stenosis due to fibromuscular dysplasia being the most common cause (2). All children with hypertension who need more than one drug should be investigated for a renovascular cause (3). While renal artery stenosis in adults is usually located at the ostium, in children it can be located more peripherally, even in the segmental arteries, and easily missed during ultrasound examination (4). Surprisingly, the selective angiography in our patient revealed a small network of tortuous arteries in the lower part of the left kidney (Fig. 1). There was no sign of significant arteriovenous shunting or formation of aneurysms, but the findings were believed to represent a small, congenital, arteriovenous malformation (AVM). Arteriovenous malformations, arteriovenous fistulas, aneurysms or aberrant vessels all represent a heterogenous group of diseases and aetiologies. Congenital AVMs of the kidney are rare, with a prevalence of less than 1% among the general population. AVMs are direct communications between the renal arteries and veins, via enlarged, tortuous vascular spaces, and can sometimes be seen using Doppler sonography (5). Most AVMs remain asymptomatic, but haematuria, renin-induced hypertension, abdominal pain, affected kidney function, polyuria and electrolyte abnormalities have been described (6). The diagnosis can be difficult, as ultrasound, computed tomography and magnetic resonance imaging often are normal. Selective angiography remains the gold standard for diagnosis. There is one case report in the literature that describes the association between AVMs and polyuria. That patient had severe hypertension, polyuria and underwent nephrectomy (7). In our patient, a multidisciplinary team decision was made to perform an endovascular embolisation. After coiling of the small, tortuous arteries seen during diagnostic angiography, further arteries supplying the pathological network appeared (Fig. 2). Therefore, we performed more extensive coil embolisation than anticipated, resulting in devascularisation of approximately 50% of the left kidney. Our patient had earlier consulted doctors because of nocturnal enuresis, probably indicating polyuria, and he was still symptomatic when he presented with hypertension. His nocturnal enuresis ceased the day after embolisation and has, so far, not recurred. Studies in adults have shown that hypertension is related to nocturnal polyuria and has a prevalence of 50–70% (8,9). The mechanisms are unclear. Some studies have reported a positive relationship between the sodium renal excretion and blood pressure levels, thus ‘resetting’ the pressurenatriuresis curve (10). In addition, a diurnal variation in arginine vasopressin secretion has been shown to be positively correlated with hypertension (11). Several case reports describe malignant hypertension and polyuria in connection with renal artery stenosis (6,12,13). In our case, a small vessel malformation affecting a lower segment of the kidney was enough to cause symptomatic hypertension. The goal of embolisation is permanent occlusion of all feeders and the nidus of the AVM. Takabayashi et al. successfully embolised 30 cases of congenital AVM (14). At least 59% of patients with congenital AVM and hypertension responded to embolisation. It may take 2–3 months

Fourteen‐year‐old boy with severe hypertension and monosymptomatic nocturnal enuresis (Case Presentation)

CASE PRESENTATION A 14-year-old boy, with known monosymptomatic nocturnal enuresis, was presented with syncope after a head trauma while playing soccer and was found to be hypertensive. He had been playing soccer 6 days a week until admission and was in good physical condition, with normal weight and height (50th percentile). A year earlier, he had been seen at the outpatient clinic due to therapy-resistant enuresis, where they tried alarm, desmopressin, acupuncture and chiropractor treatment without success. His blood pressure had not been measured, and he had suffered from headaches and nausea for a year. On admission, his blood pressure was 154/86 (>95th percentile for height, sex and age). His hypertension was confirmed, with 24-h ambulatory blood pressure monitoring showing a mean blood pressure of 160/86 mmHg (>95th percentile for age, sex and height). Family history of hypertension, renal and cardiac disease was negative. Creatinine, electrolytes, endo-

Improved infarction rates in fibroids after the introduction of contrast-enhanced ultrasound during uterine artery embolization:

Background In order to achieve sustained symptom control and minimize the risk of recurrence, uterine artery embolization (UAE) should aim at complete infarction of all fibroids. Purpose To retrospectively evaluate the infarction rate of uterine fibroids in patients that had undergone uterine artery embolization (UAE) after the introduction of contrast-enhanced ultrasound (CEUS) during UAE procedures at our institution. Material and Methods Thirty patients treated with UAE between February 2006 and August 2009 were included. MR images obtained before, at 3 months, and 12 months after the procedure were reviewed. We evaluated volume changes in dominant fibroids as well as the infarction rate of all fibroids in each patient. Clinical results were evaluated by reviewing the medical records. The study was approved by the institutional review board. Results CEUS was technically successfully performed during the UAE procedure in all patients. In five cases the endpoint of embolization was adjusted based on findings at CEUS. The mean volume shrinkage of dominant fibroids was 39.8% after 3 months and 59.8% after 12 months. There was complete infarction of all fibroid tissue in 97% of patients at 3 months and 96% at 12 months. No major complications were observed. Conclusion After the introduction of CEUS during UAE procedures in our institution, high infarction rates were achieved.

Portal vein embolization before surgery for liver tumours

BACKGROUND Radical resection is the only long-term cure for malignant liver tumours. An important contraindication for surgery is that the liver remnant would be too small. Embolization of the portal vein in the tumour-bearing side of the liver may induce growth of the healthy part and thereby render liver resection possible. MATERIAL AND METHODS 18 patients, aged 35 - 71 years, underwent portal vein embolization in the period 2002 - 2006. An interventional radiological percutaneous transhepatic technique was used. RESULTS The liver remnant increased with 45 % (median), range 9 - 100 %, in all patients. Liver resection could be done and was performed in 10 patients. Due to tumour progression, resection could not be done in seven patients. One patient was excluded from surgery due to serious side effects of chemotherapy. Four-year survival for patients with metastases from colorectal cancer (n=9) was 58 %. INTERPRETATION Portal vein embolization results in a substantial increase of liver volume. The technique effectively increases the number of patients eligible for liver surgery. It is possible for patients treated with this technique to obtain the same long-term survival as those primarily regarded to be operable. Advanced radiological technology is needed to exclude patients who would not profit from the procedure.

ALBI and P-ALBI grade in Child-Pugh A patients treated with drug eluting embolic chemoembolization for hepatocellular carcinoma

Background Treatment outcome for hepatocellular carcinoma (HCC) is related to tumor burden and liver function. Grading systems assessing liver function need validation in different clinical settings. Purpose To evaluate drug-eluting embolic transarterial chemoembolization (DEE-TACE) in Child–Pugh A HCC with respect to albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (P-ALBI) grade. Material and Methods Forty-nine patients with Child–Pugh class A, diagnosed with HCC and allocated to DEE-TACE treatment, were retrospectively analyzed regarding tumor and treatment characteristics, radiological response (mRECIST) one month post treatment, overall survival (OS), and adverse events (AEs; CTCAE, grades ≥3) with respect to ALBI and P-ALBI grade. Results There were 21 ALBI 1 patients, 29 P-ALBI 1 patients, and 19 patients were both ALBI and P-ALBI 1. Objective response rate was 74% with no statistically significant difference for ALBI (1 vs. 2; P = 0.08), or P-ALBI (1 vs. 2; P = 0.49). OS was 14.8 months (range = 1.7–62.0; ALBI 1 vs. 2: P = 0.08; P-ALBI 1 vs. 2: P = 0.003). OS in responders with ALBI 1 and 2 was 28.9 vs.10.2 months (P = 0.02), and P-ALBI 1 and 2 was 26.7 vs. 8.6 months (P < 0.001). In multivariate analyses, both ALBI 2 (HR = 2.4, P = 0.02) and P-ALBI 2 (HR = 3.3, P < 0.01) were negative prognostic factors for survival. There were 15 AEs in 13 patients, with hepatic failure only occurring in ALBI 2 and P-ALBI 2 patients. Conclusion P-ALBI grade 1 and 2 differentiated survival in Child–Pugh A patients treated with DEE-TACE. Both grading systems can differentiate survival in patients responding to treatment.

MRgHIFU – experimental perivascular volumetric ablation in the liver

Thermal ablation techniques using heat conduction (e.g. radiofrequency ablation) are sensitive to the cooling effect of blood flow, the heat sink effect. Thermal ablation by high intensity ultrasound guided by magnetic resonance imaging (MRgHIFU), is less dependent on heat conduction, and produces sharply delineated ablated volumes. The aim of this study was to ablate adjacent to large hepatic and portal veins, to study the heat sink effect on the ablation cells, as well as vessel wall patency. A secondary aim was to study features of second sonication cycles.