Suresh Vedantham

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension A Scientific Statement From the American Heart Association

Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.

UTERINE ARTERY EMBOLIZATION FOR THE TREATMENT OF UTERINE LEIOMYOMATA MIDTERM RESULTS

INTRODUCTION The authors review their midterm experience with uterine artery embolization for the treatment of uterine fibroids. MATERIALS AND METHODS Sixty patients were referred for permanent polyvinyl alcohol (PVA) foam particle uterine artery embolization during an 18-month period. Detailed clinical follow-up and ultrasound follow-up were obtained. RESULTS Bleeding was a presenting symptom in 56 patients and pain was a presenting symptom in 47 patients. All patients underwent a technically successful embolization. One of the patients underwent unilateral embolization. Fifty-nine patients underwent bilateral embolization. Of all patients undergoing bilateral embolization, at last follow-up (mean, 16.3 months), 81% had their uterus and had moderate or better improvement in their symptoms. Ninety-two percent of these patients also had reductions in uterine and dominant fibroid volumes. Overall, the mean uterine and dominant fibroid volume reduction were 42.8% and 48.8%, respectively (mean follow-up, 10.2 months). One infectious complication that necessitated hysterectomy occurred. CONCLUSION Uterine artery embolization for the treatment of uterine fibroids is a minimally invasive technique with low complication rates and very good clinical efficacy.

Uterine artery embolization: An underused method of controlling pelvic hemorrhage

Transcatheter arterial embolization has recently emerged as a highly effective percutaneous technique for controlling acute and chronic genital bleeding in a wide variety of obstetric and gynecologic disorders. Benefits for the patient and health care system have included low complication rates, avoidance of surgical risks, fertility preservation, and shorter hospitalizations. In this article the current indications for pelvic embolotherapy, types of embolotherapy, technical considerations, immediate success rates, causes of failure, complications, and outcome expectations are discussed. Our comprehensive literature review and clinical experience suggest that embolization should be used before surgical treatment of nonmalignant pelvic bleeding in many clinical settings, including postpartum, postcesarean, and postoperative bleeding. It is our strong belief that this form of therapy is underused, and the primary purpose of this article is to emphasize its developing role as a highly effective, relatively noninvasive method of treating genital bleeding.

Preliminary experience with uterine artery embolization for uterine fibroids

PURPOSE To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for fibroid-related vaginal bleeding and pelvic pain refractory to hormonal therapy and myomectomy. MATERIALS AND METHODS Eleven patients (aged 27-55 years; mean, 44.2 years; none desiring future pregnancy) with refractory vaginal bleeding and/or chronic pelvic pain related to uterine leiomyomata underwent uterine artery embolization with use of polyvinyl alcohol (PVA) particles. Clinical improvement was assessed by detailed questionnaire at 2-9 months (mean, 5.8 months) after the procedure. Sonographic measurements of the uterus and dominant masses were obtained before and at 2 months after the procedure. RESULTS All 11 patients underwent technically successful embolization. Eight of nine women who completed the follow-up questionnaire reported noticeable symptomatic improvement, including three women with complete resolution of symptoms. One woman (the only patient undergoing unilateral embolization) exhibited no clinical response. Another patient developed endometritis and pyometra 3 weeks after the procedure, necessitating hysterectomy. Large reductions in uterine volume (average, 40%) and dominant fibroid size (average, 60%-65%) were sonographically demonstrated. CONCLUSION Uterine artery embolization represents a promising new method of treating fibroid-related menorrhagia and pelvic pain. Further investigation will be required to assess clinical response and durability, identify appropriate candidates, and define the optimal angiographic technique and PVA particle size.

Image-guided tumor ablation: standardization of terminology and reporting criteria.

The field of interventional oncology with use of image-guided tumor ablation requires standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison between treatments that use different technologies, such as chemical (ethanol or acetic acid) ablation, and thermal therapies, such as radiofrequency (RF), laser, microwave, ultrasound, and cryoablation. This document provides a framework that will hopefully facilitate the clearest communication between investigators and will provide the greatest flexibility in comparison between the many new, exciting, and emerging technologies. An appropriate vehicle for reporting the various aspects of image-guided ablation therapy, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings, are outlined. Methods for standardizing the reporting of follow-up findings and complications and other important aspects that require attention when reporting clinical results are addressed. It is the groups intention that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication in this field that lead to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes. The intent of this standardization of terminology is to provide an appropriate vehicle for reporting the various aspects of image-guided ablation therapy.

Definition of post‐thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization

Summary.  The post‐thrombotic syndrome (PTS) is increasingly recognized to be a common and important complication of deep venous thrombosis (DVT). Because there is no ‘gold standard’ objective test to establish its presence, PTS is diagnosed primarily on the basis of the presence of typical symptoms and clinical signs in a limb that was affected by DVT. As a wide variety of definitions of PTS have been used by researchers, it is difficult to compare data across studies and to formally combine data in meta‐analyses. In a step towards standardization of the measurement of PTS in clinical studies, available scales and evidence to support their utility to diagnose PTS and to classify its severity were reviewed and discussed at the Control of Anticoagulation Subcommittee of the International Society on Thrombosis and Haemostasis (Vienna, July 2008).

Transcatheter Therapy for Hepatic Malignancy: Standardization of Terminology and Reporting Criteria

The field of interventional oncology includes tumor ablation as well as the use of transcatheter therapies such as embolization, chemoembolization, and radioembolization. Terminology and reporting standards for tumor ablation have been developed. The development of standardization of terminology and reporting criteria for transcatheter therapies should provide a similar framework to facilitate the clearest communication among investigators and provide the greatest flexibility in comparing established and emerging technologies. An appropriate vehicle for reporting the various aspects of catheter directed therapy is outlined, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings. Methods for standardizing the reporting of outcomes toxicities, complications, and other important aspects that require attention when reporting clinical results are addressed. It is the intention of the group that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication for reporting the various aspects of transcatheter management of hepatic malignancy that will translate to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes.

The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies A Scientific Statement From the American Heart Association

The purpose of this scientific statement is to provide an up-to-date overview of the postthrombotic syndrome (PTS), a frequent, chronic complication of deep venous thrombosis (DVT), and to provide practical recommendations for its optimal prevention, diagnosis, and management. The intended audience for this scientific statement includes clinicians and other healthcare professionals caring for patients with DVT. Members of the writing panel were invited by the American Heart Association Scientific Council leadership because of their multidisciplinary expertise in PTS. Writing Group members have disclosed all relationships with industry and other entities relevant to the subject. The Writing Group was subdivided into smaller groups that were assigned areas of statement focus according to their particular expertise. After systematic review of relevant literature on PTS (in most cases, published in the past 10 years) until December 2012, the Writing Group incorporated this information into this scientific statement, which provides evidence-based recommendations. The American Heart Association Class of Recommendation and Levels of Evidence grading algorithm (Table 1) was used to rate the evidence and was subsequently applied to the draft recommendations provided by the writing group. After the draft statement was approved by the panel, it underwent external peer review and final approval by the American Heart Association Science Advisory and Coordinating Committee. External reviewers were invited by the American Heart Association. The final document reflects the consensus opinion of the entire committee. Disclosure of relationships to industry is included with this document (Writing Group Disclosure Table). View this table: Table 1. Classification of Recommendations and Levels of Evidence ### Background DVT refers to the formation of blood clots in ≥1 deep veins, usually of the lower or upper extremities. PTS, the most common long-term complication of DVT, occurs in a limb previously affected by DVT. PTS, sometimes referred to as postphlebitic syndrome or secondary venous stasis syndrome, is considered a …

Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal.

Suresh Vedantham, MD, Patricia E. Thorpe, MD, John F. Cardella, MD, Chair, Clement J. Grassi, MD, Nilesh H. Patel, MD, Hector Ferral, MD, Lawrence V. Hofmann, MD, Bertrand M. Janne d’Othée, MD, Vittorio P. Antonaci, MD, Elias N. Brountzos, MD, Daniel B. Brown, MD, Louis G. Martin, MD, Alan H. Matsumoto, MD, Steven G. Meranze, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert J. Min, MD, Calvin D. Neithamer Jr., MD, Dheeraj K. Rajan, MD, Kenneth S. Rholl, MD, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Richard B. Towbin, MD, Bret N. Wiechmann, MD, and David Sacks, MD, for the CIRSE and SIR Standards of Practice Committees

Reporting Standards for Endovascular Treatment of Lower Extremity Deep Vein Thrombosis

Suresh Vedantham, MD, Clement J. Grassi, MD, Hector Ferral, MD, Nilesh H. Patel, MD, Patricia E. Thorpe, MD, Vittorio P. Antonacci, MD, Bertrand M. Janne d’Othée, MD, Lawrence V. Hofmann, MD, John F. Cardella, MD, Sanjoy Kundu, MD, Curtis A. Lewis, MD, MBA, Marc S. Schwartzberg, MD, Robert J. Min, MD, and David Sacks, MD, for the Technology Assessment Committee of the Society of Interventional Radiology