Tetsuya Katsumori

Infarction of Uterine Fibroids After Embolization: Relationship Between Postprocedural Enhanced MRI Findings and Long-Term Clinical Outcomes

PurposeTo retrospectively evaluate the relationship between the degree of infarction of uterine fibroids on enhanced MRI after embolization and long-term clinical outcomes.MethodsDuring 92 months, 290 consecutive patients with symptomatic uterine fibroids were treated with embolization; 221 who underwent enhanced MRI before embolization and 1 week after embolization were included in this study. The infarction rates of all fibroid tissue were assessed using enhanced MRI after embolization. Patients were divided into three groups according to the infarction rates: group A (100% infarction, n = 142), group B (90–99% infarction, n = 74), group C (<90% infarction, n = 5). The cumulative rates of clinical outcomes were compared among groups using the Kaplan-Meier limited method.ResultsGroup A had a significantly higher rate of symptom control than groups B and C. The cumulative rates of symptom control at 5 years were 93%, 71%, and 60% in groups A, B, and C, respectively. Group A had a significantly lower rate of gynecologic intervention after embolization than groups B and C. The cumulative rates of additional gynecologic intervention at 5 years were 3%, 15%, and 20% in groups A, B, and C, respectively.ConclusionsThe degree of infarction of uterine fibroids after embolization on enhanced MRI was related to long-term clinical outcomes. Complete infarction of all fibroid tissue can induce a higher rate of symptom control, with a lower rate of additional gynecologic intervention in the long term compared with incomplete infarction of fibroid tissue.

An adult case of recurrent arteriovenous malformation after “complete” surgical excision: a case report

BACKGROUND Complete surgical excision of arteriovenous malformations (AVM) documented by postoperative angiography is considered a cure. However, recent reports have shown that AVMs in children may recur after negative postoperative angiograms, and some suggest that it may reflect the immaturity of their cerebrovasculature. This case report demonstrates that AVM in adults may also recur, despite postoperative angiograms confirming complete removal. CASE DESCRIPTION This 28-year-old man presented in 1994 with a focal motor seizure and was found to have an AVM in the right frontal lobe. He underwent surgical excision of the AVM; postoperative angiograms taken immediately after surgery and 15 days later showed no residual AVM. He remained free of symptoms after surgery and it was considered that a complete removal had been achieved. In 1998 he developed a subarachnoid hemorrhage, and subsequent angiograms revealed a small AVM in an adjacent location. CONCLUSION This is the oldest patient reported in the literature with a recurrence of AVM, despite postoperative angiograms confirming complete removal. Angiographically invisible immature vessels, which might have been left in the surgical field, might have formed a new malformation later. We still believe that such recurrence must be very rare after AVM surgery, but we now recommend follow-up angiography at yearly intervals to our patients.

Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids

To determine whether women will experience permanent amenorrhea following uterine artery embolization for fibroids, and whether rates of onset differ in the long term according to age at the time of the procedure.

Magnetic Resonance Angiography of Uterine Artery: Changes with Embolization Using Gelatin Sponge Particles Alone for Fibroids

PurposeTo assess uterine artery recanalization, together with tumor devascularization, after embolization using gelatin sponge particles alone for fibroids.MethodsTwenty-seven patients underwent uterine artery embolization (UAE) for fibroids using only gelatin sponge particles. The angiographic endpoint of embolization was defined as near stasis of contrast medium in the ascending segment of the uterine artery. All patients underwent contrast-enhanced magnetic resonance angiography (MRA) before and 4 months after UAE, and contrast-enhanced magnetic resonance imaging (CE-MRI) before, 1 week after, and 4 months after UAE. The visualization of the uterine arteries before and 4 months after UAE was assessed using MRA. The infarction rates of the largest tumor were assessed using CE-MRI 1 week after UAE.ResultsMRA 4 months after UAE showed 100% (53/53) of the descending and transverse segments, and 88% (43/49) of the ascending segments that had been noted on baseline MRA. The visualization of the ascending segments on MRA 4 months after UAE was identical to that on baseline MRA in 20 of 27 patients (74%). CE-MRI showed complete infarction of the largest tumor in 22 of 27 patients (81%), and 90–99% infarction of the largest tumor in the remaining 5 of 27 patients (19%).ConclusionBased on the MR study, in most cases uterine artery recanalization occurred, together with sufficient devascularization of fibroids, after UAE using gelatin sponge particles alone.

Effective segmental chemoembolization of advanced hepatocellular carcinoma with tumor thrombus in the portal vein.

AbstractPurpose: Evaluate therapeutic results of transcatheter segmental hepatic artery chemo-oily-embolization (segmental TAE) against advanced hepatocellular carcinomas (HCC) accompanied by portal tumor thrombus (PTT). Methods: Segmental TAE was performed in nine patients with hepatic cirrhosis and advanced HCCs accompanied by PTT. Four subsegmental portal branches were obstructed by PTT in three patients, and two were obstructed in the remaining six patients. TAE was performed into the targeted segmental hepatic artery followed by embolization with gelatin sponge particles. Results: In one patient undergoing subsequent resection, a marked anticancer effect on the PTT was demonstrated histologically. In the eight other patients who did not undergo subsequent resection, the cumulative survival rates were 67% at 6 months, 44% at 1 year, and 22% at 2 years. No serious complications were noted. Conclusions: This therapeutic approach is thought to be a useful treatment for HCC with PTT, because it reinforces anticancer effects and can be performed more safely than conventional transcatheter arterial embolization.

Intracerebral hemorrhage after transcatheter thrombolysis of non-occluding superior mesenteric artery thrombosis

We performed transcatheter thrombolysis on a 64-year-old man with non-occluding superior mesenteric artery (SMA) thrombosis because his severe symptoms could not be controlled with medication. An enhanced computed tomography (CT) scan revealed intramural thrombosis in the SMA. We were concerned that the narrowing of the SMA lumen might progress to complete occlusion, resulting in a high likelihood of mortality. After dissolution of the SMA thrombosis, the original symptoms almost completely disappeared. However, intracranial hemorrhage occurred 8 hr after thrombolysis, requiring surgical intervention. Transcatheter thrombolysis is thought to be a useful treatment for SMA thrombosis, especially in elderly patients with a high operative risk; however, the possibility of intracerebral hemorrhage must be taken into consideration.

Tris-acryl gelatin microspheres versus gelatin sponge particles in uterine artery embolization for leiomyoma

Background Tris-acryl gelatin microspheres (TAGM) and gelatin sponge particles (GS) have been used in uterine artery embolization (UAE) for leiomyoma. No direct comparisons of both embolic agents have been reported. Purpose To compare the outcomes of UAE with TAGM with those of UAE with GS for uterine leiomyoma. Material and Methods This was a non-randomized, single-institute, non-inferiority study. Between July 2008 and August 2015, 67 consecutive patients with symptomatic leiomyoma underwent UAE. GS was used for the first 49 patients and TAGM was used for the following 18 patients. The primary endpoint was tumor infarction on contrast-enhanced magnetic resonance imaging (MRI) 1 week after UAE. The secondary endpoints were changes in symptoms and quality-of-life scores with UFS-QOL questionnaires at 4 months, and adverse events (AEs) in the 4 months after UAE. Results The baseline characteristics of both groups were similar. Complete or nearly complete tumor infarction (≥90%) was achieved in 94.4% (17/18) of the TAGM group and 93.6% (44/47) of the GS group. This difference (0.8%; 95% CI, –11.9% to 13.5%) indicated the non-inferiority of the TAGM group to the GS group, with a pre-specified non-inferiority margin of 20%. No significant differences were observed in improvements in symptoms or quality-of-life scores at 4 months (P = 0.56 and P = 0.19) or in 4-month AEs (P = 0.29). Conclusion The outcomes of UAE with TAGM were comparable to those of UAE with GS, suggesting that both embolic agents are acceptable for the treatment of leiomyoma.

Microsurgical Removal of Snagged Stent Retriever During Endovascular Embolectomy for Acute Ischemic Stroke

BACKGROUND Catheter-based endovascular thrombectomy has gained popularity for use in patients with acute large-vessel occlusion; however, various complications have been reported. Herein, we present a unique, serious procedure-related complication. CASE DESCRIPTION A 91-year-old woman with acute middle cerebral artery (MCA) occlusion underwent endovascular thrombectomy with a stent retriever, but the device could not be retrieved from the horizontal segment of MCA during the procedure. Subsequently, she underwent emergency craniotomy. The lodged stent was extracted with microforceps using a counter-stretch of the vessels, so as not to avulse the perforating arteries. The stent device was retrieved uneventfully through a sheath introducer that was inserted through the femoral artery. Postprocedural indocyanine green video angiography showed complete recanalization of the MCA and internal cerebral artery. CONCLUSIONS This is a rare case in which successful open surgery was performed to retrieve a snagged stent retriever, with successful recanalization of the large cerebral artery occlusion.

Volume of embolic agents in uterine artery embolization for leiomyoma: relation to baseline MRI

Abstract Purpose: To assess whether pre-procedural MRI findings predict the volume of tris-acryl gelatin microspheres (TAGM) used in uterine artery embolization (UAE) for leiomyomas. Material and methods: This was a retrospective, single-institution study. Between June 2014 and December 2017, 73 patients with leiomyomas underwent UAE with TAGM alone. Univariate and multivariate analyses were performed to assess the relationships between the volume of TAGM and baseline parameters. Technical outcomes, tumor infarction on post-procedural contrast-enhanced MRI, and complications were evaluated. Results: Technical success was achieved in all patients. Infarction of ≥90% of the total leiomyoma volume was observed in 93% (67/72) of patients. No major complications were noted. The mean (SD) volume of 500- to 700-μm particles used in all (73/73) patients was 10.3 ± 4.6 ml. The multivariate analysis revealed that uterine volume (p = .034) correlated with the 500- to 700-μm TAGM volume. Seven hundred- to 900-μm particles were added for 70% (51/73) of patients at a mean (SD) volume of 3.6 ± 4.6 ml. The dominant tumor volume (p = .028) correlated with the 700- to 900-μm TAGM volume. Conclusion: The dominant tumor or uterine volume on pre-procedural MRI was directly associated with the volume of TAGM required for embolization of leiomyomas.

First Versus Second Uterine Artery Embolization for Symptomatic Leiomyoma

OBJECTIVE The purpose of this study was to compare the outcomes of second uterine artery embolization (UAE) with those of first UAE for symptomatic uterine leiomyoma. MATERIALS AND METHODS In this single-institution retrospective study, between December 1997 and May 2016 first UAE was performed on 423 consecutively registered patients and second UAE on 11 consecutively registered patients to treat leiomyoma. The primary endpoint was infarction of all tumor tissue as seen at postprocedural contrast-enhanced MRI. The secondary endpoints were angiographic findings, embolization, MRI, and clinical outcomes 1 year after UAE. The outcomes were compared between the two groups. Multivariable linear regression analysis was performed to assess independent correlations with tumor infarction. RESULTS Most of the baseline demographic features and technical outcomes in the two groups were similar. In the second UAE group, all but one uterine artery was reopened. More collateral vessels were observed at the second UAE (1.1/patient versus 0.23/patient, p = 0.043). Contrast-enhanced MRI after UAE revealed that the tumor infarction rate was significantly lower in the second UAE group (69.8 ± 33.9% vs 96.8 ± 9.0%, p = 0.025). The difference remained significant after adjustments for possible confounders (p < 0.001). Whether UAE was a first or a second procedure was significantly associated with tumor infarction rate (p < 0.001). The uterine volume reduction rate 1 year after UAE was significantly lower in the second UAE group (33.4 ± 18.1% versus 46.9 ± 16.6%, p = 0.008). No other 1-year outcomes were significantly different between the groups. CONCLUSION Second UAE was effective but inferior to first UAE in that it resulted in less tumor infarction at contrast-enhanced MRI and had a lower uterine volume reduction rate.