Mark B. Saker

The Impact of Uterine Fibroid Embolization on Resumption of Menses and Ovarian Function

PURPOSE To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function. METHODS The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test. RESULTS Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses. CONCLUSION The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.

The Vascular Impact of Uterine Artery Embolization: Prospective Sonographic Assessment of Ovarian Arterial Circulation

PURPOSE The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE. MATERIALS AND METHODS Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test. RESULTS Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001). CONCLUSION Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Peripherally Inserted Central Catheters: Guidance with Use of US versus Venography in 2,650 Patients

PURPOSE To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance. MATERIALS AND METHODS With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test. RESULTS During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001). CONCLUSION There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

Treatment of Stomal Variceal Hemorrhage with TIPS: Case Report and Review of the Literature

We report a case in which recurrent hemorrhage from stomal varices was successfully treated by placement of a TIPS in a patient with prior colectomy for inflammatory bowel disease. Although several treatment options have been reported for this entity we believe that TIPS offers minimally invasive and definitive treatment.

Early failure of aortoiliac kissing stents: histopathologic correlation.

JVIR 2000; 11:333–336 THE application of bilateral iliac stents, or kissing stents, for atherosclerotic disease of the aortic bifurcation has been described in the literature (1–4). They have been described in cases of failed or suboptimal percutaneous transluminal angioplasty, or as primary therapy. Some practitioners favor the use of stents as a primary form of treatment, due to optimal immediate angiographic and hemodynamic results when compared to percutaneous transluminal angioplasty alone. A small series of cases of kissing stents at the aortic bifurcation has been reported (4). Long-term patency rates are unknown. There is very little known about the natural history of protruding metallic stents from the iliac arteries into the abdominal aorta. We report a case of early failure of aortoiliac kissing stents, in which a surgical specimen was obtained for cytopathology analysis.

Three-dimensional MR pulmonary perfusion imaging and angiography with an injection of a new blood pool contrast agent B-22956/1

Initial evaluation of a new blood pool agent, B‐22956/1, for pulmonary imaging was performed in five domestic pigs with artificial embolism. Pre‐embolism 3D pulmonary perfusion images were first acquired by injecting an extravascular agent, gadoteridol. The pulmonary arteries of the pigs were then occluded by the artificial emboli. Post‐embolism perfusion scans were subsequently performed by injecting B‐22956/1. Additional post‐embolism high‐spatial‐resolution angiograms were also acquired. Parenchyma perfusion deficits were well depicted in the post‐embolism perfusion maps. The post‐embolism angiography clearly revealed the location and extent of the filling defects in the pulmonary vessels. Signal intensities of perfusion maps on the normal parenchyma were significantly improved (30%) by using B‐22956/1, in comparison with perfusion images using gadoteridol (P < 0.01). Many pulmonary angiograms with approximately equal contrast could be obtained even at 22 minutes after the injection of B‐22956/1. Our initial results indicate that blood pool agent B‐22956/1 may provide opportunities for whole‐lung‐coverage perfusion mapping and additional high‐resolution target angiograms after a single injection. J. Magn. Reson. Imaging 2001;14:425–432.

Validation of injection parameters for catheter-directed intraarterial gadolinium-enhanced MR angiography.

RATIONALE AND OBJECTIVES Catheter-directed intraarterial (IA) injections of gadolinium contrast agents may be used during endovascular interventions with magnetic resonance (MR) imaging guidance. Injection protocols require further validation. Using a flow phantom and swine, the authors aimed to (a) measure the optimal arterial gadolinium concentration ([Gd]) required for MR angiography and (b) validate a proposed IA injection protocol for gadolinium-enhanced MR angiography. MATERIALS AND METHODS For in vitro experiments, the authors placed a catheter in the aorta of an aorto-renal-iliac flow phantom. Injected [Gd], injection rates, and aortic blood flow rates were varied independently for 36 separate IA gadolinium injections. The authors performed 2D and 3D MR angiography with a fast spoiled gradient-recalled echo sequence. For subsequent in vivo experiments, they selectively placed catheters within the aorta, renal artery, or common iliac artery of three pigs. Injection rate and injected [Gd] were varied. The authors performed 32 separate IA gadolinium injections for 2D MR angiography. Signal-to-noise ratios (SNRs) were compared for the various combinations of injection rate and injected [Gd]. RESULTS In vitro, an arterial [Gd] of 2%-4% produced an optimal SNR for 2D MR angiography, and 3%-5% was best for 3D MR angiography. In swine, an arterial [Gd] of 1%-4% produced an optimal SNR. In the phantom and swine experiments, SNR was maintained at higher injection rates by inversely varying the injected [Gd]. CONCLUSION Dilute arterial [Gd] is required for optimal IA gadolinium-enhanced MR angiography. To maintain an optimal SNR, injection rates and injected [Gd] should be varied inversely. The postulated injection protocol was validated.

Aortic air embolus following pulmonary tumor radiofrequency ablation

Aortic air embolism following a computed tomography (CT) guided percutaneous transthoracic procedure is a rare occurrence, but one that can have dire consequences. We present a case of a 48-year old female diagnosed with aortic air embolism during percutaneous radiofrequency ablation of a pulmonary mass. A large amount of intra-aortic air can be seen on the CT images just before the patient suffered acute cardiac arrest. Although this is a rare occurrence, recognition and management of this complication is important for physicians who perform any percutaneous transthoracic procedures.