Early Results from a United States Trial of Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia

PurposeTo report early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH).Materials and MethodsFrom January 2012 to March 2013, 72 patients were screened and 20 patients underwent treatment. Patients were evaluated at baseline and selected intervals (1, 3, and 6 mo) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)–related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 mo). Complications were monitored and reported per Society of Interventional Radiology guidelines.ResultsEmbolization was technically successful in 18 of 20 patients (90%); bilateral PAE was successful in 18 of 19 (95%). Unsuccessful embolizations were secondary to atherosclerotic occlusion of prostatic arteries. Clinical success was seen in 95% of patients (19 of 20) at 1 month, with average AUA symptom score improvements of 10.8 points at 1 month (P < .0001), 12.1 points at 3 months (P = .0003), and 9.8 points at 6 months (P = .06). QOL improved at 1 month (1.9 points; P = .0002), 3 months (1.9 points; P = .003), and 6 months (2.6 points; P = .007). Sexual function improved by 34% at 1 month (P = .11), 5% at 3 months (P = .72), and 16% at 6 months (P = .19). Prostate volume at 6 months had decreased 18% (n = 5; P = .05). No minor or major complications were reported.ConclusionsEarly results from this clinical trial indicate that PAE offers a safe and efficacious treatment option for men with BPH.     

The Role of Accessory Obturator Arteries in Prostatic Arterial Embolization

In 9 of 491 patients (1.8%) who underwent prostatic arterial embolization (PAE) for benign prostatic hyperplasia from March 2009–November 2013, prostatic arteries arose from the external iliac artery via an accessory obturator artery (AOA). Computed tomography angiography performed before the procedure identified the variant and allowed planning before the procedure. The nine AOAs were catheterized from a contralateral femoral approach. Bilateral PAE was technically successful in the nine patients. There was a mean decrease in international prostate symptom score of 6.5 points and a mean prostate volume reduction of 15.1% (mean follow-up, 4.8 mo) in the nine patients.     

Carbon Dioxide Contrast Enhancement for C-Arm CT Utility for Treatment Planning during Hepatic Embolization Procedures

A pilot study was performed to evaluate the use of carbon dioxide (CO₂) as a contrast medium for C-arm computed tomography (CT). C-arm CT using CO₂ was performed during embolization procedures in12 patients with hepatic malignancies and severe iodine allergy or high risk for nephrotoxicity. C-arm CT using gadolinium or iodinated contrast medium was performed for comparison. Of segmental arteries identified by conventional contrast enhancement, 96% were also seen with CO₂ enhancement, but subsegmental arteries were not reliably depicted. CO₂ enhancement identified 60% of tumors. Small, hypovascular, and infiltrative tumors were difficult to detect. CO₂ is a promising alternative intraarterial contrast agent for C-arm CT.     

Coil Embolization of the Splenic Artery: Impact on Splenic Volume

PurposeTo determine the impact of coil embolization of the splenic artery on splenic volume based on computed tomography (CT) imaging.Materials and MethodsSplenic artery embolization (SAE) was performed in 148 consecutive patients over an 8-year period in an institutional review board–approved retrospective study. Of these, 60 patients (36 men; mean age, 49 y) had undergone contrast-enhanced CT before and after SAE with a mean time interval of 355 days. Pre- and postembolization splenic volumes were calculated with volume-rendering software. Presence of Howell–Jolly bodies was ascertained on laboratory tests. A trauma control group consisted of 39 patients with splenic laceration and follow-up CT but no splenic intervention.ResultsSAE in trauma patients resulted in an insignificant decrease in mean spleen size from 224 cm³ to 190 cm³ (P = .222). However, postembolization splenic volume was significantly smaller than follow-up volume in the trauma control group (353 cm³; P < .001). In nontrauma patients, the mean splenic volume decreased from 474 cm³ to 399 cm³ after SAE (P = .068). Multivariable analysis revealed that coil pack location was the only factor significantly affecting resultant splenic volume (P = .016). For trauma and nontrauma patients, distal embolization resulted in significant splenic volume loss (P = .034 and P = .013), whereas proximal embolization did not. No patients had persistent circulating Howell–Jolly bodies after SAE. No patients required repeat embolization or splenectomy.ConclusionsCoil embolization of the splenic artery resulted in a modest but significant decrease in splenic volume when performed distally; proximal embolization resulted in an insignificant volume change.     

Results of Bronchial Artery Embolization for the Treatment of Hemoptysis Caused by Neoplasm

PurposeTo describe experience with bronchial artery embolization (BAE) in a cohort of patients with cancer.Materials and MethodsAll consecutive patients with cancer and at least one episode of hemoptysis that required BAE during a 14-year period were included in this observational retrospective review. The endpoints of the study were immediate success, recurrence of hemoptysis, mortality resulting from hemoptysis, and all-cause mortality.ResultsImmediate control of bleeding was achieved in 31 of 40 patients (77.5%). Recurrence requiring BAE occurred in eight patients (20%). Cumulative hemoptysis control rate was 0.90 (95% confidence interval [CI], 0.80–1.0) at 1 month and 0.65 (95% CI, 0.44–0.86) at 6 months. Probability of survival was 0.75 (95% CI, 0.62–0.88) at 1 month, 0.42 (95% CI, 0.27–0.57) at 6 months, 0.36 (95% CI, 0.21–0.51) at 12 months, and 0.08 (95% CI, 0.0–0.18) at 3 years.ConclusionsBAE is an effective and safe technique in the treatment of hemoptysis in patients with cancer. Nevertheless, mortality resulting from hemoptysis and recurrence rate are high among these patients secondary to progression of the underlying disease.     

Embolization of Angiographically Visible Type I and II Utero-ovarian Anastomoses during Uterine Artery Embolization for Fibroid Tumors: Impact on Symptom Recurrence and Permanent Amenorrhea

PurposeTo compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE).Materials and MethodsA retrospective, institutional review board–approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05.ResultsTwenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1).ConclusionsThere were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.     

Quantitative Assessment of Lipiodol Deposition after Chemoembolization: Comparison between Cone-Beam CT and Multidetector CT

PurposeTo evaluate the ability of cone-beam computed tomography (CBCT) performed directly after transarterial chemoembolization to assess ethiodized oil (Lipiodol) deposition in hepatocellular carcinoma (HCC) and compare it with unenhanced multidetector computed tomography (CT).Materials and MethodsConventional transarterial chemoembolization was used to treat 15 patients with HCC, and CBCT was performed to assess Lipiodol deposition directly after transarterial chemoembolization. Unenhanced multidetector CT was performed 24 hours after transarterial chemoembolization. Four patients were excluded because the margin of tumor or area of Lipiodol deposition was unclear. The image enhancement density of the entire tumor and liver parenchyma was measured by ImageJ software, and tumor-to-liver contrast (TLC) was calculated. In addition, volumetric measurement of tumor and Lipiodol was performed by semiautomatic three-dimensional volume segmentation and compared using linear regression to evaluate consistency between the two imaging modalities.ResultsThe mean value of TLC on CBCT was not significantly different from TLC on multidetector CT (337.7 HU ± 233.5 vs 283.0 HU ± 152.1, P = .103).The average volume of the whole tumor and of only the regions with Lipiodol deposition and the calculated average percentage of Lipiodol retention on CBCT were not significantly different compared with multidetector CT (tumor volume, 9.6 cm³ ± 11.8 vs 10.8 cm³ ± 14.2, P = .142; Lipiodol volume, 6.3 cm³ ± 7.7 vs 7.0 cm³ ± 8.1, P = .214; percentage of Lipiodol retention, 68.9% ± 24.0% vs 72.2% ± 23.1%, P = .578). Additionally, there was a high correlation in the volume of tumor and Lipiodol between CBCT and multidetector CT (R² = 0.919 and 0.903).ConclusionsThe quantitative image enhancement and volume analyses demonstrate that CBCT is similar to multidetector CT in assessing Lipiodol deposition in HCC after transarterial chemoembolization.     

Apparent Diffusion Coefficient of Uterine Leiomyoma as a Predictor of the Potential Response to Uterine Artery Embolization

PurposeTo determine the utility of the apparent diffusion coefficient (ADC) of uterine leiomyoma for prediction of the potential response to uterine artery embolization (UAE).Materials and MethodsThis prospective study included 49 patients with uterine leiomyomas who underwent diffusion-weighted magnetic resonance (MR) imaging before UAE between May 2011 and January 2012. All patients also underwent 3-month follow-up MR imaging after UAE. Using conventional and diffusion-weighted MR imaging sequences, 72 uterine leiomyomas ≥ 3 cm were prospectively evaluated. The volume of each leiomyoma was calculated, and quantitative measurement of ADC was performed. Regression analysis was used to evaluate the relationship between ADC and volumetric response after UAE. Receiver operating characteristic curve analysis was performed to determine the sensitivity and specificity of ADC for prediction of the potential response to UAE. Interclass correlation coefficient analysis was used to assess interobserver variability between two radiologists.ResultsVolume reduction rates of leiomyomas after UAE ranged from 0.2%–89.1% (mean, 44.1%). ADC ranged from 0.559 × 10^?3 mm²/s to 1.814 × 10^?3 mm²/s (mean, 1.170 × 10^?3 mm²/s). ADC was statistically significantly related to volumetric response of leiomyomas (P = .014). Using a threshold of 1.092 × 10^?3 mm²/s, the sensitivity and specificity of ADC for prediction of > 50% volume reduction of the leiomyoma after UAE were 82.6% and 52.3%, respectively. Using a threshold of 1.023 × 10^?3 mm²/s, the sensitivity and specificity of ADC for prediction of < 30% volume reduction were 80.8% and 33.3%, respectively. The interclass correlation coefficient for measuring ADC of uterine leiomyomas between two radiologists was 0.98.ConclusionsADC of uterine leiomyomas was significantly related to the volume reduction after UAE. ADC may be useful in predicting the potential response to UAE. A high ADC of the uterine leiomyoma may be associated with a greater volume reduction after UAE.     

Treatment of Acute Hemoptysis by Bronchial Artery Embolization with the Liquid Embolic Agent Ethylene Vinyl Alcohol Copolymer

PurposeTo determine the technical and clinical success of bronchial artery embolization (BAE) with the liquid embolic agent ethylene vinyl alcohol (EVOH) copolymer in patients with acute hemoptysis.Materials and MethodsThirty-four patients (25 male; mean age, 58 y; range, 13–78 y) who underwent BAE with EVOH were retrospectively reviewed. Reasons for acute hemoptysis included lung cancer (44%), pulmonary metastases (12%), bronchiectasis (21%), arteriovenous malformation (5%), tuberculosis (6%), aspergilloma (3%), acute respiratory distress syndrome (3%), anticoagulant overdose (3%), and scar tissue (3%). Technical and clinical success of BAE were retrospectively assessed.ResultsEmbolization was technically successful in 94% of patients. Additional embolization material was needed in 4 patients (12%). The immediate clinical success rate was 94% (32 of 34); in 2 patients (6%), hemoptysis recurred immediately after the intervention or could not be stopped. Periinterventional minor complications included headache (n = 1), fever (n = 1), and acute renal failure (n = 1). During follow-up (mean, 8.8 mo), 5 patients had a recurrence of hemoptysis (15%).ConclusionsThe use of EVOH copolymer for BAE in patients with acute hemoptysis is technically successful and safe and has a good clinical outcome with a low number of recurrences.     

Inferior Mesenteric Artery Collaterals to the Uterus during Uterine Artery Embolization: Prevalence,Risk Factors,and Clinical Outcomes

PurposeTo evaluate the prevalence of inferior mesenteric artery (IMA) collaterals to the uterus found during uterine artery embolization (UAE), associated risk factors, and clinical outcomes.Materials and MethodsThe records of 559 women who underwent UAE during the period 2008–2011 for uterine fibroids or adenomyosis found on magnetic resonance imaging were retrospectively analyzed. If IMA collaterals to the uterus were suspected on aortography performed after embolization, selective angiography was performed. Risk factors for IMA collaterals to the uterus were analyzed, including the presence of adenomyosis, baseline uterine volume, or prior pelvic surgery.ResultsCollaterals to the uterus were found from the ovarian artery (n = 21; 3.8%), IMA (n = 7; 1.3%), round ligament artery (n = 1; 0.2%), and internal pudendal artery (n = 1; 0.2%). IMA collaterals were found in seven patients. Of 185 patients, 6 (3.2%) had adenomyosis, with or without fibroids, which was significantly more frequent than the 1 (0.27%) of 374 patients who had fibroids only (P = .006). On multiple logistic regression analysis, the presence of adenomyosis (odds ratio, 19.556; P = .0168) and uterine volume (odds ratio, 1.003; P = .0069) were independent factors for the presence of IMA collaterals. Of the seven patients with IMA collaterals, embolization was not attempted in six, resulting in clinical failure in four. One patient who underwent IMA embolization with coils experienced clinical improvement.ConclusionsThe IMA was the second most common (1.3%) source of collaterals to the uterus. IMA collaterals were more frequent in patients with adenomyosis than in patients with fibroids only, resulting in high frequency of treatment failure.     

Uterine Artery Embolization Using a Transradial Approach: Initial Experience and Technique

This study investigates the feasibility of performing uterine artery embolization (UAE) via transradial access (TRA). Growing evidence demonstrates significant benefits of TRA versus standard transfemoral access during percutaneous coronary intervention, now making it the preferred approach at many centers worldwide. At a single institution from March 2013 to October 2013, 29 consecutive patients were treated by transradial UAE. Technical success rate was 100%, with no immediate major or minor complications. The radial artery was patent at 1-month follow-up evaluation in all cases. These preliminary data suggest that transradial UAE is feasible and safe.     

Live MR Angiographic Roadmapping for Uterine Artery Embolization: A Feasibility Study

PurposeTo assess the feasibility of live magnetic resonance (MR) angiography roadmapping guidance for uterine artery (UA) embolization (UAE) for fibroid tumors.Materials and MethodsTwenty patients underwent UAE with live MR angiographic roadmapping. The pre-acquired MR angiography scan was coregistered with the live intraprocedural fluoroscopy stream to create a visual roadmap to direct the microcatheter during UAE. Patient radiation dose, as measured by dose–area product (DAP), procedure time, contrast medium volume, and fluoroscopy time, was recorded. For the first 10 patients, an additional parameter of contrast medium volume needed to catheterize each UA was recorded.ResultsIn all 20 patients (40 UAs), the MR angiography overlay on live fluoroscopy was accurate and allowed for successful catheterization of the UA, resulting in a technical success rate of 100%. In the subset of the initial 20 UAs (ie, the first 10 patients) in which this data point was recorded, 17 (85%) were successfully catheterized with no iodinated contrast medium at all, by purely relying on the MR angiography roadmap. Mean procedure time was 45 minutes (range, 30–99 min), mean contrast agent dose was 75 mL (range, 46–199 mL), and mean DAP was 155 Gy·cm² (range, 37–501 Gy·cm²).ConclusionsLive MR angiographic roadmapping is feasible and accurate for catheter guidance during UAE.     

The Effect of Uterine Artery Embolization on Premenstrual Symptoms in Patients with Symptomatic Fibroids or Adenomyosis

PurposeTo evaluate whether uterine artery embolization (UAE) can reduce the premenstrual symptoms in women undergoing UAE for fibroid tumors or adenomyosis.Materials and MethodsAmong 141 women who underwent UAE for symptomatic fibroid tumors or adenomyosis at a single institution between March 2011 and February 2013, 54 premenstrual symptoms in 39 patients were prospectively analyzed. Premenstrual symptoms were rated by the patient on a scale of 0 to 10, with 0 representing no symptom and 10 representing the baseline severity. The change in premenstrual symptom score was calculated by subtracting the baseline score from the post-UAE score. At 3–6 months after UAE, each woman also completed a symptom severity questionnaire to assess the severity of menstrual bleeding to compare the changes in premenstrual symptoms scores between women with and without menorrhagia.ResultsBack pain, headache, and gastrointestinal symptoms (eg, constipation, indigestion, lower abdominal pain) were significantly improved after UAE (P < .05). Muscle pain, fatigue, nervousness, breast tenderness, and systemic edema were also improved, but not significantly so. The mean premenstrual symptom score change in patients with menorrhagia was significantly greater than in those without menorrhagia (−6.4 vs −3.7; P = .044).There was no correlation between the degree of menorrhagia score change and the degree of premenstrual symptom score change (P = .186).ConclusionsUAE could be a method to alleviate some premenstrual symptoms in patients with uterine fibroid tumors or adenomyosis.     

Renal Artery Fibromuscular Dysplasia in 2,640 Renal Donor Subjects: A CT Angiography Analysis

PurposeTo present the incidence, demographics, and clinical presentation of patients diagnosed with renal fibromuscular dysplasia (FMD) who underwent computed tomography (CT) angiography for evaluation of living renal donor protocol.Methods and MaterialsA retrospective review was performed from January 1, 2000, to December 31, 2011 on patients who underwent CT angiography for evaluation of living renal donor protocol. Of 2,640 patients identified, only patients with a diagnosis of FMD by the radiology report underwent independent reader evaluation of CT angiography for the presence of FMD and associated characteristics. The demographics, medical history, and presentation were reviewed using the electronic medical chart.ResultsThe independent readers who evaluated CT angiography identified a diagnosis of FMD in 68 patients (2.6%; 59 female) with an average age of 52 years ± 10. Unilateral FMD was observed in 46 patients (68%), and bilateral FMD was observed in 22 patients (32%). Three patients had aneurysms of the renal artery. Comorbidities included hypertension (n = 21, 31%), dyslipidemia, (n = 13, 19%), history of migraines (n = 3, 4%), and history of smoking (n = 14, 21%). No patients had diabetes mellitus, coronary artery disease, or family history of FMD. Of 21 patients (31%) with a history of hypertension, 13 patients (62%) were treated with antihypertensive medications.ConclusionsThe incidence of FMD in patients who underwent CT angiography for evaluation of living renal donor protocol is 2.6%.     

Combined Antegrade Femoral Artery and Retrograde Popliteal Artery Recanalization for Chronic Occlusions of the Superficial Femoral Artery

PurposeTo evaluate the efficacy and safety of a dual femoral–popliteal approach in the supine position after failed antegrade recanalization attempts in chronic total occlusion (CTO) of the superficial femoral artery (SFA).Materials and MethodsFrom May 2011 to October 2012, 21 patients underwent dual femoral–popliteal recanalization for CTO of the SFA, with a mean lesion length of 87.4 mm ± 5.8. When contralateral antegrade recanalization of SFA occlusions via the common femoral artery could not be achieved, the occlusions were intrainterventionally accessed by retrograde approach via the popliteal artery, which was punctured anteriorly with gently flexed knee and crus extorsion. When the SFA had been recanalized, further angioplasty and stent placement procedures were completed via the femoral artery.ResultsA technical success rate of 100% (entailing puncture of the popliteal artery and SFA recanalization) was achieved, and no hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, or other complications developed. During a mean follow-up of 9.8 months ± 1.5, claudication severity, rest pain, and toe ulcers improved significantly. The pulse of the distal arteries, as well as the filling of the veins, could be distinctly felt. Ankle-brachial index changed from 0.48 ± 0.17 to 0.84 ± 0.11 at 1 year after intervention (P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 80%, and 42%, respectively.ConclusionsA dual femoral–popliteal approach in the supine position is an alternative backup option after failed attempts at the antegrade approach for patients with proximal barriers in CTO or lesions with major extending collateral vessels.