Kyran Dowling

Outpatient Uterine Artery Embolization for Symptomatic Uterine Fibroids: Experience in 49 Patients

PURPOSE To assess the feasibility of performing uterine artery embolization as an outpatient treatment for symptomatic uterine fibroids. MATERIALS AND METHODS Forty-nine consecutive patients (mean age, 44.5 years; range, 28-54 years) underwent uterine artery embolization during a 12-month period. Embolization was performed with 350-500 microm polyvinyl alcohol particles (44 of 49) or Gelfoam pledgets (five of 49). At discharge, patients were given instructions regarding the constitutional symptoms to expect after embolization. A specific medication regimen consisting of prochlorperazine, ketorolac, meperidine, and hydrocodone was prescribed for relief of these symptoms. All patients were telephoned within 24 hours of discharge. During long-term follow-up, a questionnaire was administered to all patients to evaluate the periprocedural experience. Three-month clinical follow-up was available in 26 patients and 6-month imaging follow-up was available in 16 patients. RESULTS Fourteen patients presented with menorrhagia, six had bulk-related symptoms (abdominal distension, stress incontinence, pelvic pain), and 29 had both. Technical success for bilateral embolization was 98%. Forty-seven of 49 patients were discharged to home 6-8 hours after the procedure; two patients required overnight observation in an ambulatory unit (one because of postprocedure hypertension and one because of a late procedure completion time). At the first follow-up phone call, reported symptoms included pelvic pain/cramping in 83.7% (41 of 49), fatigue in 75.5% (37 of 49), nausea/vomiting in 46.9% (23 of 49), and a nonpurulent vaginal discharge in 18.4% (nine of 49). These symptoms were satisfactorily controlled with discharge medications in 48 of 49 patients. No patients returned to the hospital or visited an emergency room during the first 48 hours after discharge. Forty-six of 49 patients were satisfied with the decision for home discharge. The average uterine volume reduction in 16 patients with 6-month imaging follow-up was 47.5%; 88.5%, of patients (23 of 26) with 3-month clinical follow-up reported improvement or elimination of symptoms. CONCLUSION With defined telephone follow-up, staff availability, and a protocol designed to alleviate the postprocedure constitutional symptoms, uterine artery embolization is both safe and effective when performed as an outpatient procedure.

Results of Iliac Artery Stent Placement in Patients Younger than 50 Years of Age

PURPOSE To determine long-term outcome in patients 50 years of age or younger treated with iliac artery stent placement. MATERIALS AND METHODS The records of 412 patients who underwent iliac artery stent placement during a 62-month study period were reviewed retrospectively. Forty-two patients younger than age 50 (mean age = 45 y) at the time of stent placement were included in the study population. Presenting symptoms included claudication (47%), rest pain (17%), ulceration/tissue loss (31%), and blue toe syndrome (5%). Anatomic, hemodynamic, and clinical success rates of the stent placement procedure were assessed. Stent patency rates were calculated by life-table methods. RESULTS Fifty-nine iliac lesions were treated with stents; 62% of patients underwent treatment of a single lesion whereas 38% had multiple lesions treated. Thirty-one percent were treated after a failed angioplasty procedure and 69% were treated with stent placement primarily. After stent placement, 34 patients (82%) experienced symptomatic relief, although eight of these patients (19%) underwent a planned ipsilateral infrainguinal bypass procedure during the same hospitalization. During follow-up, five patients (12%) required a bypass procedure as a result of stent failure and two patients (5%) required below-knee amputation. Seven patients (17%) required endovascular stent revision, with none requiring additional surgery. At 1, 2, and 3 years, the primary patency rates were 86%, 72%, and 65%, and the secondary patency rates were 90%, 88%, and 88%, respectively. CONCLUSIONS Iliac stent placement successfully addresses the presenting symptoms of young patients with peripheral vascular disease and results in patency rates that are similar to those reported in a more general population. With appropriate postprocedural surveillance, restenosis can be addressed in many patients with use of endovascular techniques, limiting the need for surgical revision.

Early ambulation after diagnostic angiography using 4-f catheters and sheaths: a feasibility study.

Purpose: To assess the feasibility and safety of early ambulation in patients undergoing transfemoral diagnostic angiography using 4-F catheters or sheaths. Methods: In this prospective study approved by the institutional review board, patients undergoing diagnostic angiography were randomized to ambulate 3 or 6 hours after catheter or sheath removal. All patients were assessed for hematoma formation, pseudoaneurysm development, and other groin complications during the in-hospital recovery period and after 30 days. Patient satisfaction and comfort level were also assessed by survey. Results: Of 110 patients (66 men; mean age 64.9 ± 12.8 years) who participated in this study, 47 were randomized to the 6-hour (6-H) group and 63 to the 3-hour (3-H) group. In the 3-H and 6-H groups, respectively, a 4-F catheter was used in 45 (71%) and 35 (74%) patients and a 4-F sheath in 18 (29%) and 12 (26%). No clinically significant groin complications were encountered in either group. Moderate to severe discomfort was reported in 9 (16%) of the 56 patients responding to the discomfort survey in the 3-H group compared to 10 (26%) of the 38 in the 6-H survey respondents. Conclusions: It is feasible and safe to ambulate patients 3 hours after diagnostic angiography performed with a 4-F catheter with or without a 4-F sheath. Early ambulation of patients after angiography has the additional benefits of increasing patient satisfaction and resource utilization.

Use of a collagen plug device to seal a subclavian artery puncture secondary to intraarterial dialysis catheter placement.

O SCVIR, 1999 THE role of endovascular therapies for the treatment of traumatic arterial lesions has expanded in recent years. In the past, percutaneous treatment of such lesions was limited to arteries that could be embolized with coils, gelatin foam, or other agents. Traumatic pseudoaneurysms may be amenable to coil embolization or, more recently, in the common femoral artery region, to ultrasoundguided compressive occlusion. The advent of covered endovascular stent grafts has expanded the role of the interventional radiologist to treat arterial injuries, especially in locations that are more difficult to approach surgically. However, one of the limitations of this technique includes the occlusion of vital branch vessels by the covered stent. Recently, two collagen plug devices have been marketed to seal arterial puncture sites after arteriography and intervention (1,2). We report our experience in a patient with a dialysis catheter placed within the subclavian artery in which a collagen plug device was used to seal the arterial puncture site.

Safety of Limited Supplemental Iodinated Contrast Administration in Azotemic Patients Undergoing CO2 Angiography

Purpose: To determine if limited doses of iodinated contrast significantly worsen the underlying renal insufficiency that had warranted the use of CO2 for diagnostic angiography. Methods: The records of 122 consecutive patients who had undergone CO2 angiography for peripheral vascular disease at our institution over a 5-year period were reviewed. The volume and type of iodinated contrast and the volume of CO2 administered were recorded. Serum creatinine measurements obtained before angiography and from 2 to 3 days after angiography were recorded. Results: One hundred patients had pre-angiography and post-angiography creatinine levels available for analysis (51 CO2 only, 49 CO2 with iodinated contrast). The average pre-treatment creatinine level was 2.8±1.5 mg/dL (range 1.8–6.6) for the CO2 only group and 3.0±1.4 mg/dL (range 1.8–8.2) for the CO2 plus iodinated contrast group (p=0.46). After angiography, the mean change in creatinine was +0.17±0.87 mg/dL for the CO2 only group and +0.03±0.98 mg/dL in the CO2 plus contrast group (p=0.27). Complications included 1 patient with a failing renal transplant who received iodinated contrast and ultimately required return to hemodialysis. A second patient had a transient 1-mg/dL rise of creatinine but did not require dialysis. Conclusions: This study supports the relative safety of CO2 angiography with the limited used of iodinated contrast supplementation for diagnostic studies or interventions in azotemic patients with peripheral vascular disease.

Uterine Fibroid Embolization without the Use of Iodinated Contrast Material

Editor: Uterine fibroid embolization (UFE) is a safe and effective therapy for women with symptomatic uterine fibroids (1). At the present time, contraindications specific to UFE are still being established. However, the relative contraindications to angiography apply to this procedure, including a history of a severe allergic reaction to iodinated contrast material. Because hysterectomy is a proven alternative to UFE, patients with a history of anaphylaxis may choose to undergo surgery rather than risk a potentially lethal reaction during UFE. We have recently performed UFE in a patient with a history of anaphylaxis to iodinated contrast material with use of CO2 and gadolinium as the angiographic con-

Management of Failing Prosthetic Bypass Grafts with Metallic Stent Placement

AbstractPurpose: To evaluate the role of metallic stents in treating stenoses involving prosthetic arterial bypass grafts. Methods: Patients undergoing stent placement within a failing prosthetic bypass graft, during a 41-month period, were reviewed for treatment outcome and complications. The indications for stent placement in 15 patients included severe claudication (n=3), rest pain (n=9), and minor or major tissue loss (n=3). Lesions were at the proximal anastomosis (n=6), the distal anastomosis (n=3), or within the graft (n=6). Results: Treatment with metallic stents was successful in all patients. There was one acute stent thrombosis, successfully treated with thrombolytic therapy. Follow-up data are available for a mean duration of 12.3 months. The mean duration of primary patency was 9.4 months with 6- and 12-month primary patency rates of 51.9% and 37.0%, respectively. The mean duration of secondary patency was 12.1 months with 6- and 12-month secondary patency rates of 80.0% and 72.7%, respectively. Two patients with discontinuous runoff and preexisting gangrene required a below-knee amputation. Six patients were revised surgically after stent placement (at a mean of 10.8 months). Three late deaths occurred during follow-up. Conclusion: Given the mortality risks of surgical revision and the reduced life expectancy of this patient population, metallic stent placement represents a viable, short-term treatment option for stenoses within or at the anastomoses of prosthetic grafts. Further evaluation is warranted to compare intragraft stent placement with surgical graft revision.