Massive postpartum hemorrhage treated with transcatheter arterial embolization: technical aspects and long-term effects on fertility and menstrual cycle

Background: Transcatheter arterial embolization (TAE) is considered a safe, life-saving procedure in postpartum hemorrhage (PPH), but its long-term effect on menstruation and fertility is unclear.

Purpose: To investigate technical aspects and the evaluation of complications, focused on menstrual cycle and fertility, using TAE in patients with PPH.

Material and Methods: A retrospective study including 20 patients (seven with vaginal and 13 with cesarean delivery) with severe PPH treated with bilateral TAE of the uterine artery was carried out. All patients were asked to answer a questionnaire regarding their post-embolization history. In six patients, the radiation dose was measured.

Results: All 20 cases underwent bilateral TAE of the uterine artery. Gelfoam was used as the embolic agent. However, after cesarean delivery in six patients who had clear contrast medium extravasation and/or pseudoaneurysm-like lesion, metallic coils had to be used in order to achieve hemostasis. No major short- or long-term complications were registered. Normal menses resumed in all patients. Four patients had a total of five full-term and two preterm pregnancies, and all delivered healthy infants by cesarean section with no recurrence of PPH. The mean radiation dose to the ovaries was 586 mGy (range 204-729 mGy).

Conclusion: TAE in patients with PPH is safe and has no major short- or long-term side effects. A patient managed with TAE can expect return of normal menses and preservation of future fertility and successful pregnancies. PPH after cesarean section might need to be embolized with metallic coils in addition to Gelfoam in order to achieve secure hemostasis.     

Embolization of accessory left gastric artery to prevent acute gastric mucosal lesions in patients undergoing repeated hepatic arterial infusion chemotherapy

Purpose: To retrospectively evaluate results of selective embolization of the accessory left gastric artery prior to repeated hepatic arterial infusion chemotherapy using a port-catheter system.

Material and Methods: Of 22 patients with unresectable advanced liver cancer who underwent percutaneous implantation of a port-catheter system, an accessory left gastric artery was revealed by arteriography in 16 patients before and in six patients after port-catheter implantation. The right gastric artery was embolized to prevent gastric mucosal lesions in all 22 patients. In addition, the accessory left gastric artery was selectively embolized for the same purpose using from one to six microcoils, which were from 3 to 5 mm in diameter. Within 10 days after implantation, arteriography was performed while contrast material was infused via the port.

Results: Selective embolization of the accessory left gastric artery was successful in all 22 patients. No complication related to embolization of this artery occurred in any patient. A gastrointestinal mucosal lesion developed in only one case during hepatic arterial infusion chemotherapy, but was unrelated to the accessory left gastric artery.

Conclusion: Prophylactic embolization of the accessory left gastric artery is useful to avoid development of a gastrointestinal mucosal lesion resulting from hepatic arterial infusion chemotherapy.     

Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) in patients with bleeding/rebleeding duodenal ulcers.

Material and Methods: Over a 6-year-period, 40 consecutive patients with bleeding/rebleeding after endoscopic therapy and/or surgery for duodenal ulcer were included in the study. Superselective angiographic catheterization and coil embolization were performed by the same interventional radiologist.

Results: Lasting hemostasis was achieved in 26 of 40 patients (65%). Transfusion requirement was reduced from median 14 (range 3-35) units of blood before TAE to 2 (range 0-53) units after TAE. Ten patients died, five because of continuous bleeding. No adverse effects as a result of TAE were seen.

Conclusion: TAE is an effective and safe treatment in a significant proportion of patients with bleeding duodenal/rebleeding ulcers after therapeutic endoscopy and/or surgery.     

Graves病动脉栓塞治疗并发症分析

目的探讨甲状腺动脉栓塞治疗Graves病的并发症及其产生因素。方法对28例Graves病患者的甲状腺动脉造影、介入栓塞治疗、并发症及其产生因素进行分析,并作中期随访。结果1年有效率78.6%(治愈 好转),复发率14.2%。脑梗死2例(7.1%),1例治疗后恢复,1例并发甲状腺功能亢进危象抢救无效死亡;1例术后有一过性甲状腺功能减退,1例术后发生一过性甲状旁腺功能减退,无永久性的甲状腺和甲状旁腺功能减退;1例术后有较重的栓塞后综合征反应。其余并发症均经治疗后消失,随访至少1年以上,无其他不良反应。结论反流误栓是甲状腺动脉栓塞术治疗Graves病并发症产生的重要原因,栓塞时必须作超选插管、避开危险吻合、防止反流误拴,严格透视下操作,以期降低并发症、提高疗效。     

A simplified method for continuous hepatic arterial port-catheter system placement not requiring catheter end-hole occlusion

Purpose: To evaluate the efficacy of hepatic port-catheter system placement without distal catheter tip occlusion or gastroduodenal artery embolization distal to the catheter tip.

Material and Methods: A port-catheter system was percutaneously implanted in 29 patients (16 men, 13 women; mean age 65.6 years) with unresectable liver cancer. Persistent blood flow through the end hole of the catheter was verified immediately and 1-10 days after catheter placement.

Results: In all cases, percutaneous port-catheter placement was successfully performed. In seven of 29 (24.1%) patients, flow through the end hole of the catheter was verified immediately after the procedure. However, no flow was seen 1-10 days after the procedure.

Conclusion: It is not necessary to occlude the end hole of the catheter tip and embolize the gastroduodenal artery beyond the catheter tip when placing a port-catheter system for repeated hepatic arterial infusion chemotherapy.     

Acceleration of primary liver tumor growth rate in embolized hepatic lobe after portal vein embolization

Background: Portal vein embolization (PVE) is now widely accepted as a useful preoperative procedure in selected patients undergoing extended hepatectomy. However, the effect of PVE on the growth of liver tumors has not been fully elucidated.

Purpose: To retrospectively evaluate the effects of PVE on the growth of liver tumors in the embolized lobes.

Material and Methods: Eight patients with a primary liver tumor, six hepatocellular carcinomas (HCC) and two cholangiocellular carcinomas (CCC), were studied. The growth rates of the tumors in the embolized lobes and non-embolized liver parenchyma were calculated using the computed tomography (CT) volume values at the time of tumor identification, and before and after PVE.

Result: The median tumor growth rate was 0.59 cm³/day (range 0.22-6.01 cm³/day) before PVE and 2.37 cm³/day (range 0.29-13.97 cm³/day) after PVE (P = 0.018). The tumor growth acceleration ratios ranged from 1.50 to 7.46 (median 2.65) in the six HCCs, and were 1.00 and 1.32 in the two CCCs. There was no apparent correlation between the tumor growth rate after PVE and the growth rate of non-embolized liver parenchyma (median 6.00 cm³/day, range 1.24-11.0 cm³/day).

Conclusion: Liver tumor growth in an embolized lobe accelerates after PVE, in patients with HCC.     

Percutaneous transcatheter embolization in arterial injuries of the lower limbs

Purpose: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries.

Material and Methods: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate.

Results: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67±0.91 days.

Conclusion: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.     

Transcatheter arterial embolization for massive hemoptysis in patients with coal workers' pneumoconiosis: an 11-year experience

Background: Transcatheter arterial embolization (TAE) is a safe and well-established treatment option to control hemoptysis, but there are few studies focused on treating hemoptysis accompanying coal workers' pneumoconiosis (CWP).

Purpose: To evaluate the immediate and long-term efficacy of TAE for control of massive hemoptysis in patients with CWP, and to clarify the factors which influence the frequency of rebleeding.

Material and Methods: This study included 34 CWP patients with massive hemoptysis who were treated with 47 TAE sessions over the last 11 years. Immediate (within 1 month) and long-term outcomes (mean 37 months, range 1 month-11 years) were evaluated retrospectively. The relationships between the frequency of rebleeding and the type of CWP, angiographic findings, and presence of tuberculosis were evaluated.

Results: The immediate success rate was 91.2% (31/34). In 23 patients (68%), hemoptysis did not recur on long-term follow-up. In eight patients who received repeated procedures for recurrent hemoptysis, bleeding was discovered in the non-bronchial systemic artery (n = 13) or bronchial artery (n = 7). The frequency of recurrent hemoptysis was higher in cases with complicated pneumoconiosis (n = 7) than in cases of the simple type (n = 1; P = 0.029). There was no statistical difference between rebleeding and angiographic findings or the presence of tuberculosis.

Conclusion: TAE is an effective treatment modality for controlling massive hemoptysis in patients with CWP. However, many non-bronchial systemic collaterals contribute to recurrent hemoptysis. Furthermore, there is a high probability of rebleeding in patients with the complicated type of CWP, and extra care must be taken in the embolization procedure.     

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma by placing a temporary catheter via the subclavian route

Background: A permanent reservoir implantation is considered mandatory for hepatic arterial infusion chemotherapy (HAIC) of hepatocellular carcinoma (HCC). Since treatment sessions of HAIC may be limited for these end-staged patients, a simple alternative technique for this treatment is desirable.

Purpose: To evaluate the feasibility of placing a temporary catheter for HAIC in advanced HCC patients.

Material and Methods: 25 advanced HCC patients underwent HAIC with drugs delivered from a temporary catheter which was placed percutaneously by puncturing the left subclavian artery under ultrasound guidance. A course of chemotherapy consisted of five consecutive daily infusions of 5-fluorouracil, cisplatin, mitomycin C, and leucovorin. The catheter was removed on the 6th day. Therapy was repeated every 4-6 weeks with maximal number of courses of up to six. The total courses of HAIC in each patient, the catheter-placed-related complications, tumor response rate, and median survival of the patients were registered.

Results: A total of 77 courses of HAIC were performed with 100% technical success of catheter placement (1-6 courses in each patient, average 3.1 courses). The overall response rate was 20%, with complete response in two patients and partial response in three patients. Eleven (55%) of the 20 non-responders died within 5 months (mean HAIC, two courses). None of the patients experienced complications such as catheter occlusion, hepatic arterial thrombosis, cerebral infarction, or local infection.

Conclusion: With fewer catheter-related complications, HAIC by temporary catheter placement via subclavian puncture could be a treatment option.     

Diffusion-weighted magnetic resonance imaging of cerebrospinal fluid in patients with and without communicating hydrocephalus

Background: Recent concepts about cerebrospinal fluid (CSF) circulation in communicating hydrocephalus (CoHy), which is also termed “restricted arterial pulsation hydrocephalus,” suggest reduced arterial pulsations of subarachnoid vessels with a smaller amount of CSF shifted in subarachnoid spaces during the early systole. The postulated restriction of subarachnoid arterial pulsations in CoHy should induce a smaller motion artifact and reduced local stream effects in CSF in magnetic resonance (MR) diffusion-weighted imaging (DWI).

Purpose: To investigate the maximum diffusivity in CSF in patients with and without CoHy using DWI.

Material and Methods: 12 patients without CSF circulation disturbances and six cases with proven CoHy were assessed. Diffusion was measured in six noncollinear directions without triggering the arterial pulse wave (scan time 6:45 min, voxel size 2×2×2 mm). Due to expected artifacts, the calculated maximum diffusivity was called apparent diffusivity. Regional high and low apparent diffusivity was assessed in CSF spaces on newly created 3D CSF motion maps.

Results: Patients with regular CSF circulation exhibited high apparent diffusivity in CSF in basal subarachnoid spaces, whereas apparent diffusivity was low there in patients with CoHy.

Conclusion: DWI opens a feasible approach to study CSF motion in the neurocranium. Restricted arterial pulsations seem to be involved in CoHy.     

Imaging of four-corner fusion (SLAC arthrodesis) of the wrist with 64-slice computed tomography

Purpose: To find out whether it is possible to evaluate the healing of wrist arthrodesis, carried out with a metallic spider plate, by means of 64-slice computed tomography (CT).

Material and Methods: 18 CT examinations were performed in 12 patients 2 weeks to 37 months following scapholunate advanced collapse (SLAC) arthrodesis fixed with a metallic plate. Ten patients also had plain films of the wrist. Radiation doses were estimated.

Results: Plain films were difficult to evaluate due to overprojection of the spider plate. With 64-slice CT, however, it was possible to evaluate the healing process in all patients in spite of metallic artifacts. Radiation doses were low.

Conclusion: The healing of SLAC arthrodesis of the wrist is difficult to evaluate with conventional radiography due to the metallic plate. By means of 64-slice CT, however, it was possible to “see under” the plate in all 12 patients.     

Parameters obtained by hepatobiliary scintigraphy have significant correlation with biochemical factors early after liver transplantation

Background: Early postoperative hepatobiliary scintigraphy after liver transplantation is performed worldwide, but data on its significance for graft function are currently limited.

Purpose: To examine the correlation between the result of early postoperative hepatobiliary scintigraphy and pre- and postoperative biochemical parameters in liver transplantation (LTx) patients.

Material and Methods: Six parameters of hepatobiliary scintigraphy using ^99mTc mebrofenin were statistically analyzed in 108 LTx patients: 1) half-life of the activity of elimination of mebrofenin from the blood; 2) total clearance of mebrofenin from the blood due to all possible routes; 3) half-life of the activity due to liver uptake; 4) clearance of mebrofenin from the blood due to liver uptake; 5) time to maximal uptake in the liver; and 6) the hepatic extraction fraction (HEF) and biochemical data. Analysis between patients with preoperative normal liver function, familial amyloid polyneuropathy (FAP), and end-stage liver disease (non-FAP) was also performed.

Results: Univariate and multivariate analysis revealed that total bilirubin postoperative day 3 correlated with all three scintigraphic parameters, and peak aspartate aminotransferase and alanine aminotransferase correlated with HEF. The analysis between patients with FAP and non-FAP revealed no significant difference of scintigraphic data between the two groups.

Conclusion: A significant correlation between early postoperative scintigraphic results and biochemical parameters was demonstrated.     

Long-term computed tomography follow-up after open surgical repair of abdominal aortic aneurysms

Purpose: To describe the findings on computed tomography (CT) of the aortic sac (AS) in patients operated on for abdominal aortic aneurysm (AAA) with insertion of a coated Dacron prosthesis.

Material and Methods: A prospective study of 36 consecutive patients operated on for AAA over 2 years and followed longitudinally with CT for up to 10 years.

Results: All patients had a fluid-filled AS on CT 7-10 days postoperatively. At 6 months, the AS had decreased in most patients, mainly in the antero-posterior diameter, and in two had disappeared completely. In five patients with complications, the AS increased in size. The AS disappeared completely at 10 years' follow-up in 13 patients. When present, a retroperitoneal hematoma always disappeared after 6 months.

Conclusion: These data indicate that the AS after graft implantation will diminish gradually but will persist for at least 6 months. Usually the transverse diameter is bigger than the antero-posterior diameter. If the AS enlarges and becomes rounded and distended with an inhomogeneous interior, it might be a sign of graft infection. In these cases an ultrasound-guided or CT-guided puncture is recommended.     

Determination of the effect of a single hemodialysis session on retrobulbar blood hemodynamics by color Doppler ultrasonography

Background: Retrobulbar hemodynamic alterations can occur during hemodialysis sessions, and patients with chronic renal failure may experience visual problems.

Purpose: To evaluate the effect of single-session hemodialysis on retrobulbar vessel hemodynamics by color Doppler ultrasonography.

Material and Methods: Thirty-five patients were included in the study. Retrobulbar blood flows were examined before and after dialysis sessions. Doppler spectral patterns of retrobulbar blood flow were evaluated. The t test for paired samples and the Wilcoxon matched-pairs signed-rank test were used for comparing the flow values before and after dialysis.

Results: Systolic and diastolic blood flow velocities of the ophthalmic artery, central retinal artery, central retinal vein, nasal posterior ciliary artery, and temporal posterior ciliary artery were found to be decreased bilaterally after hemodialysis sessions. No significant change was observed in resistivity index values after hemodialysis sessions.

Conclusion: Our findings reveal that retrobulbar circulation was disturbed after a single hemodialysis session.     

Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract

Purpose: To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT)

Material and Methods: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated.

Results: In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT.

Conclusion: S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.     

Balloon occlusion test of the internal carotid artery: correlation with stump pressure and 99mTc-HMPAO SPECT

Purpose: To evaluate the correlation of stump pressure during balloon occlusion test and relative cerebral blood flow (relative CBF) as measured by ^99mTc-hexamethylpropyleneamine oxime (^99mTc-HMPAO) single-photon emission computed tomography (SPECT) after test occlusion.

Material and Methods: Balloon occlusion test of the internal carotid artery (ICA) was performed in 25 patients. The count ratio of occluded hemisphere to non-occluded hemisphere was calculated on ^99mTc-HMPAO SPECT. The ratio of mean stump pressure to mean arterial pressure during carotid occlusion during the balloon occlusion test was compared with the count ratio of ^99mTc-HMPAO SPECT.

Results: Two patients failed to tolerate even brief carotid occlusion. The other 23 patients showed no ischemic deficit during occlusion of the ICA. In 13 of these 23 patients, the ratios of mean stump pressure to mean arterial pressure were more than 50%, and the count ratios on SPECT were more than 85%. In 10 of 23 patients, the ratios of mean stump pressure to mean arterial pressure were less than 50%, and the count ratios on SPECT were variable.

Conclusion: Maintenance of a mean stump pressure of 50% or more of the mean systemic pressure during test occlusion indicates adequate cerebral blood flow during carotid occlusion.     

Hepatocellular carcinoma in association with hepatic focal nodular hyperplasia

Purpose: To report the association between hepatocellular carcinoma (HCC) and hepatic focal nodular hyperplasia (FNH) and the possible impact on clinical decision-making with regard to resective approaches in patients with FNH.

Material and Methods: We retrospectively analyzed the findings in 77 adult patients who underwent liver resections for FNH between October 1989 and September 2001 at our center. HCC within the confines of FNH was found in two patients. We demonstrate the magnetic resonance imaging (MRI) and macroscopic and microscopic findings.

Results: Presurgical MRI demonstrated heterogeneous signal characteristics of moderately hyperintense FNH on T2-weighted images and, after IV administration of super-paramagnetic iron oxide particles, HCC in FNH was barely delineable. Both patients underwent successful right hemihepatectomy to remove the suspicious FNH with diameters of 12 and 14 cm; intralesional HCC diameters were 3 and 5 cm, respectively. Patients could be rapidly dismissed. However, one patient died after recurrence of HCC 1.5 years after surgery, whereas the other patient continues tumor-free 4 years after surgery. Alpha-feto-protein was normal in both patients.

Conclusion: In FNH with rapid growth tendency and heterogenic MR appearance, surgical removal should be considered to overcome the risk of inadequate therapy in the very rare group of patients with HCC in association with FNH.     

Ureteroscopic treatment of proximal ureter stones with the aid of an antegrade occlusion balloon catheter

Purpose: To define the role of an antegrade occlusion balloon catheter in preventing migration of proximal ureteral stones to the dilated proximal ureter during endoscopic treatment.

Material and Methods: An occlusion balloon catheter was used in 8 of 21 patients with proximal ureteral stones who underwent ureterorenoscopy. Five of the eight patients had solitary kidneys admitting with anuria and had percutaneous nephrostomy. In the other three patients, percutaneous nephrostomy and occlusion balloon catheters were placed a day before the procedure, since these patients had total obstruction and massive dilatation of the proximal ureter and renal collecting system. The balloons of occlusion catheters were inflated with 1 ml of sterile saline proximal to the stones just before ureterorenoscopy.

Results: All stones could be reached by ureterorenoscopy and treated successfully with the aid of an ultrasonic lithotripter, and no stone migration to the upper dilated collecting system was observed. Just after the operation, while the patient was still lying on the operation table, the occlusion catheter was removed. The nephrostomy catheter was removed a day later. All patients were totally stone-free after the procedures.

Conclusion: Occlusion balloon catheters increase the ureteroscopic treatment success rate in proximal ureter stones. This should be kept in mind especially when dilatation of the proximal collecting system is prominent and in cases with unsuccessful previous intervention with a retrograde stone cone catheter.     

Pulmonary cement embolism: a complication of percutaneous vertebroplasty

Background: Percutaneous vertebroplasty (PV) has recently become a very common procedure for vertebral compression fractures. Extravasation of cement, a common event associated with vertebroplasty, may lead to cement emboli in the lungs.

Purpose: To determine the frequency of pulmonary cement embolism after percutaneous vertebroplasty.

Material and Methods: Between 2002 and 2006, 128 percutaneous vertebroplasties were performed in 73 patients (56 women and 17 men) in our institution. Postprocedural chest radiographs were obtained for all patients and assessed for the presence of pulmonary cement emboli.

Results: Pulmonary cement embolism was detected on chest radiographs and confirmed with chest computed tomography (CT) in four patients treated with percutaneous vertebroplasty for osteoporotic collapse and one patient treated for multiple myeloma. The imaging finding of pulmonary cement embolism was solitary or multiple fine radiodense lines with occasional branching patterns. The frequency of pulmonary cement embolism was 6.8%.

Conclusion: An incidence of pulmonary cement embolism of 6.8% during PV was found. Close clinical follow-up, postprocedural chest radiographs, and chest CT scans, if necessary, are important for the detection of pulmonary cement embolism at an early stage.     

Bronchial stump fistula: treatment with covered, retrievable, expandable, hinged stents--preliminary clinical experience

Purpose: To evaluate the preliminary clinical efficacy and retrievability of a covered, retrievable, metallic hinged stent in the treatment of bronchial stump fistula (BPF).

Material and Methods: Between April 2003 and March 2005, eight patients with bronchial stump fistula after pneumonectomy or lobectomy were treated with two types of covered, retrievable, metallic hinged stents. Type A stent was placed in six patients and type B in two under fluoroscopic guidance. The stent was removed with a retrieval set when BPF was healed or complications occurred.

Results: Stent placement in the bronchial tree was technically successful in all patients, without procedure-related complications. Immediate closure of the BPF was achieved in all patients after the procedure. Stents were removed from all patients but one. Removal of the stents was difficult in two patients due to tissue hyperplasia. Patients were followed for 4-16 months. Placement of the stents remained stable in all patients except one due to severe cough. Permanent closure of BPF was achieved in seven (87.5%) of eight patients.

Conclusion: Use of a covered, retrievable, expandable, metallic hinged stent is a simple, safe, and effective procedure for the closure of bronchial stump fistula. Retrieval of the stent seems feasible.