Krzysztof Pyra

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure.

Background Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. Purpose To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Material and Methods Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. Results In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication – 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. Conclusion Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

Embolisation in the Therapy of Post-Partum Haemorrhage in a Patientwith a Massive Myoma

Study background: The world prevalence of post-partum haemorrhage is approx. 10.5% of pregnancies, and it is the leading mortality cause among young women, accounting for approx. 25% of fatalities. Post-partum haemorrhage is defined as over 500 ml blood loss from genitals, occurring within the first 24 hours post partum. The presented case is an example of efficacy of the embolisation procedure in the management of post-partum haemorrhage. A 29-y.o. female patient was referred to the hospital in her third pregnancy. Because of the presence of a massive myoma the patient was qualified for delivery by Caesarean section. The child was delivered. The uterine muscle was sutured. Haemostasis control - no signs of active bleeding. Three hours after the Caesarean section a massive postpartum haemorrhage developed. Oxytocin and Methylergometrin were administered intravenously, and Mizoprostol per rectum. The bleeding from the uterine cavity was still massive, and a decision was made on embolisation of uterine arteries. Methods: The procedure was performed with access via the right femoral artery, under local anaesthesia. A selective injection of a contrast medium to the left uterine artery was performed, which allowed visualisation of the uterine vascular bed with the myoma, as well as of the site of the active, massive bleeding. First the left uterine artery was embolised with particles, in order to close the vascular bed of the myoma. Then, a part of the vessel supplying the uterine muscle with the bleeding site, was closed with Spongostan gel. Results: Control angiography indicated a correctly closed left uterine artery, with no filling of the uterine vascular bed. No other sites of bleeding were detected. Conclusion: The selective embolisation of vessels in course of a postpartum haemorrhage in that case was a safe, minimally invasive and highly effective therapeutic method, that ensures an option of further pregnancies.

Elastography Improves the Diagnostic Accuracy of Sonography in Differentiating Endometrial Polyps and Submucosal Fibroids

To assess whether strain elastography may be used to visualize the different stiffness of endometrial polyps and submucosal fibroids.

Uterine artery embolisation for the treatment of symptomatic uterine fibroids

Introduction. Uterine fibroids are the most common benign uterine tumours which can be treated with conservative, surgery or minimally invasive methods. Selection of patients for embolisation seems to be essential. Aim. Assessment of efficacy and safety of uterine artery embolisation with hydrogel microparticles coated with an anti-inflammatory agent for reduction in symptomatic uterine fibroid volumes. Material and methods. In the prospective observational study carried out between January 2011 and December 2013, 206 patients with symptomatic fibroids were qualified for uterine artery embolisation. 118 aged 32 to 51 (average 39), who reported for follow-ups 3-4 months after procedures, were evaluated. According to the number of fibroids, patients with 2/4 fibroids predominated (78 patients), followed by those with single fibroids (25) and with myomatous uteri (14 patients). According to fibroid sizes, 4 groups were distinguished: < 7 cm in 77 patients, 7-12 cm in 19, > 12 cm in 8, and myomatous uteri in 14 patients Results. A mean decrease in fibroid volume in the entire study population was 62%, ranging from 9% in the patient with a hyalinised fibroid to 100% in patients with separated submucosal fibroids. Conclusions. UAE is a safe and effective treatment for symptomatic uterine fibroids. In addition to reducing the symptoms, significantly reduces their volume. The key to success is proper qualification, as well as cooperation between the radiologist and the gynecologist.

Endovascular embolisation strategies for pulmonary arteriovenous malformations

Purpose To assess the immediate efficacy of distinct embolisation devices in the endovascular treatment of pulmonary arteriovenous malformations as well as to identify and analyse the possible determinants of the technical success of the procedure. Material and methods Prospective analysis of 16 consecutive patients was carried out, who underwent transcatheter endovascular embolisation therapy for pulmonary arteriovenous malformations between 2005 and 2017. Pre- and post-procedural angiography studies were implemented to confirm the diagnosis and to evaluate the technical success defined as the complete occlusion of the feeding artery. Embolisation devices – coils, microcoils, occluders, or combination of the above – were used. All the patients were advised to conduct a follow-up computed tomography evaluation 12 months after the procedure. Results A total of 40 pulmonary arteriovenous malformations (PAVMs) were observed and embolised. The immediate technical success was achieved in all (n = 40; 100%) treated PAVMs, as confirmed by the post-procedural angiographic result. The statistical analysis revealed no significant impact of the number of PAVMs per patient (p > 0.05), their angioarchitecture (p > 0.05), localisation within the lung (p > 0.05) or particular lobe (p > 0.05), and the selection of embolisation device (p > 0.05) on the procedural success rates. The procedure-related complication rate was equal to 6.25%. Conclusions The immediate success rate of the transcatheter PAVM embolisation reached 100% in this study. The statistical model of logistic regression revealed no significant impact of the number of PAVMs per patient, their angioarchitecture, localisation, and distribution pattern, as well as device selection, on the immediate technical success of the procedure.

Endovascular treatment for superior vena cava obstruction

Summary Introduction. Superior vena cava syndrome (SVCS) is common complication of malig- nancy, the lung cancer is the most common cause. The clinical indication for superior vena cava (SVC) endovascular treatment is allevation of superior vena cava syndrome (SVCS) caused by malignant obstruction. Aim. Evaluation of safety and efficacy of SVC stenting in patients with malignant supe- rior vena cava syndrome (SVCS) n our experience. Material and methods. Between 2011 and 2014, data of 112 patients with SVC syn- drome, mostly of malignant aetiology, were retrospectively collected. The study included 68 men and 44 women (mean age n 64; range 43-79 years). Results. Stent placement was technically successful in 98% cases. Two stents were found to be obstructed after several months and patients needed repeated angioplasty. There was no stent migration to the right atrium. Haemoptysis was observed in one patient and pulmonary embolism in two cases. There were no major remote complications. Conclusions. Endovascular stenting has become a safe and cost effective treatment for patients with SVCS, providing rapid relief of symptoms and improving their quality of life. Endovascular stenting should be performed in each patient with SVCS.

Uterine artery embolisation for obstetric hemorrhages treatment

Introduction. The major causes of death in women of reproductive age are pregnancy and perinatal complications. According to the WHO data, postpartum haemorrhage (PPH) occurs in about 10.5% of deliveries worldwide and is the leading single cause of mortality amongs young women (estimated at about 25% of deaths). PPH is diagnosed as blood loss > 500 ml during vaginal delivery. Haemorrhages can be effectively treated avoiding surgical interventions by uterine artery embolisation (UAE). Aim. Assessment of efficacy and outcomes of percutaneous uterine artery embolisation for the treatment of postpartum haemorrhage and assessment the validity of prophylactic catheter balloons arteries leaving in the internal iliac artery. Material and methods. In the years 2011-2014, 12 uterine artery embolisation procedures were carried out in the Department of Interventional Radiology and Neuroradiology MU Lublin. The embolisation procedures were performed using gelatin foam or Embozene calibrated particles. The technical success was lack of contrast blood inflow into the uterine arteries. Results. In 5 cases embolisation were performed using standard catheters and gelatin foam; in 7 cases microcatheters and spherical, calibrated Embozene particles, 500 and 700 um in diameter, had to be used. In the 11 patients, the embolisation procedures effectively stopped bleedings. In one patient, hysterectomy was performed several hours after embolisation due to further bleeding. Clinical efficacy was found to be 91%. Conclusions. The procedure of percutaneous uterine artery embolisation seems to be an effective and safe method for the treatment of postpartum haemorrhage. The key to success is cooperation of gynaecologists and interventional radiologists and developed fast-track referral of patients. In some cases prophylactic artery catheterization balloon leaving in the internal iliac artery is also recommended.

Is CT still a method of monitoring patients after endovascular treatment of abdominal aortic aneurysms

Introduction. The endovascular treatment of patient with abdominal aorta aneurysms has been a recognized alternative to classic surgery. One of the most common complications is an endoleak developing due to incomplete exclusion of the aneurysmal sac from circulation. Aim. To assess the value of ultrasound contrast agents for the diagnosis of endoleaks in patients with AAA treated by stent graft implantation. Material and methods. One hundred and ninety-eight patients with AAA were treated with stent graft implantation. Follow-up examinations, i.e. preand post-contrast ultrasound and angio-CT, were performed 6 months after treatment in all patients. In each ultrasound examination, colour, power, Bflow options were used before and after contrast injection; additionally, contrast-enhanced ultrasound (CEUS) was performed after contrast administration. Results. During the follow-up examinations after 6 months, pre-contrast ultrasound performed in all options (colour, power, Bflow) revealed 16 endoleaks: 6 type IA, 4 type IB, type 2 IIA and 4 type IIB; in post-contrast ultrasound using CEUS 22 endoleaks were confirmed and additionally 4 endoleaks were diagnosed: 2 type IIA, and 2 type IIB. In angio-CT, 22 endoleaks were diagnosed: 1 type IA, 5 type IB, 4 type IIA, and 7 type IIB. None of the four additional endoleaks observed with CEUS was found in angio-CT. Conclusions. The use of ultrasound contrast media significantly increases the sensitivity of ultrasound in the diagnosis of endoleaks, particularly type II ones. CEUS examinations show the greatest sensitivity in detecting endoleaks, as they disclose the endoleaks unrecognized by other techniques, including angio-CT. Post-contrast ultrasound can replace angio-CT in monitoring patients after stent graft implantations.

Bilateral Uterine Artery Chemoembolization with Methotrexate and Gelatine Foam for Caesarean Scar Pregnancy - Case Report

C l i n M e d International Library Citation: Pyra K, Woźniak S, Czuczwar P, Szkodziak P, Sojka M (2014) Bilateral Uterine Artery Chemoembolization with Methotrexate and Gelatine Foam for Caesarean Scar Pregnancy – Case Report. A Case Report. Obstet Gynecol Cases Rev 1:003 Received: September 10, 2014: Accepted: October 27, 2014: Published: October 29, 2014 Copyright: