Percutaneous cryoablation of 100 anterior renal tumors: safety and technical success.

PURPOSE: To assess the safety, technical success, and clinical outcomes of percutaneous cryoablation (PCA) in patients with anterior renal tumors. METHODS: A retrospective analysis of patients with anterior renal tumors, defined as tumors at or anterior to the level of the renal pelvis, treated with CT-guided PCA from 2008 to 2022. Summary statistics included demographics and baseline tumor attributes. Treatment and follow-up metrics included primary and secondary technical success, adverse events (AEs) according to the SIR classification, local recurrence, overall survival (OS), and cancer-specific survival (CSS)). 100 patients (60 males; mean age: 63, mean BMI: 33, mean Charlson comorbidity index:6) with 100 anterior renal tumors were included. RESULTS: 78% of tumors were T1a and 22% T1b with mean maximal tumoral dimension of 29 mm (range: 6-62 mm) and mean distance to nearest critical structure 9 mm (range: 0-40 mm). Mean follow-up was 20.9 months (range: 3-103). 28% of PCAs required hydrodissection. Technical success was achieved in 92% of patients; with six remaining patients undergoing successful repeat PCA (secondary technical success: 98%). The remaining two patients without primary technical success were either surveilled or had a benign pathology on resulted concomitant biopsy. Four patients (4%) had major AEs (hemorrhage requiring prolonged admission, transfusion, or embolization (n = 3), perinephric abscess requiring drainage (n = 1)) and 27% had minor AEs. Eight patients (8%) had recurrence with a one-year OS of 94% and CSS of 100%. All recurrences underwent repeat ablation without additional recurrence and 3/8 (38%) were T1b and 5/8 (63%) were T1a tumors. CONCLUSION: PCA of anterior renal tumors can be performed safely with high rates of technical and oncologic success.

Uterine Vascular Anomalies: Management and Treatment Overview.

Uterine vascular anomalies (UVAs), while rare, can result in severe, life-threatening hemorrhage. An understanding of the presentation and management options for UVAs is important for interventional radiologists to appropriately evaluate and care for these patients. The authors propose a standardized terminology for UVAs to avoid confusion and conflating congenital from acquired vascular lesions, which have a different pathophysiology. Limited high-level evidence and no definitive guidelines for UVA management exist, although endovascular treatment with uterine artery embolization has generally become the first-line approach for symptomatic or persistent UVAs with high technical and clinical success rates. There is also no consensus on the optimal embolization technique; the authors propose an initial approach to first embolize the dominant uterine artery supplying the UVA with gelatin sponge, with the option to embolize the contralateral side at the time of initial embolization if there is persistent supply (avoiding bilateral empiric embolization). Repeat embolization is feasible and recommended in the setting of recurrence, and both clinical and imaging follow-up is important. Ultimately, a multidisciplinary approach with individualized patient management is needed, particularly in the face of a lack of consensus guidelines for the management of symptomatic UVAs.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding.

PURPOSE: To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB). MATERIALS AND METHODS: Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergently with UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time. RESULTS: 52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001). CONCLUSIONS: Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review.

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Transarterial embolization of T1b and T2a renal cell carcinoma prior to percutaneous cryoablation: a retrospective comparative study.

PURPOSE: To compare outcomes in patients with T1b and T2a renal cell carcinoma (RCC) treated with percutaneous cryoablation (PCA) who underwent transarterial embolization (TAE) of the RCC prior to PCA (TAE + PCA) to patients who were treated with PCA alone. METHODS: Retrospective review of all adult patients with T1b (4.1-7 cm) and T2a (7.1-10 cm) RCC treated with PCA from 2008 to 2021. Data collected included age, sex, tumor diameter, RENAL nephrometry score, technical success, adverse events (AEs), changes in serum creatinine, local control, and recurrence rates. A p value of 0.05 was considered the threshold for statistical significance. RESULTS: 13 patients with 13 RCCs (mean age: 72.7 ± 10.4; 54% male) and 35 patients with 37 RCCs (mean age: 66.7 ± 10.6; 60% male) were included in the TAE + PCA and PCA groups, respectively. The TAE + PCA group had larger mean tumor diameter (5.7 ± 1.1 cm vs. 4.7 ± 0.6 cm; p < 0.0001) and higher mean RENAL nephrometry score (8.9 ± 1.1 vs. 7.8 ± 1.5; p = 0.02). There were no differences between the groups with respect to technical success of PCA (p = 0.46), local tumor control (p = 0.3), or mean number of procedures to achieve local tumor control (p = 0.85). Mean increase in serum creatinine was not significantly different between the two groups (p = .63). Major AEs were similar between the groups (p = 1); however, the TAE + PCA group had no major hemorrhagic AEs while the PCA alone group had three (8.3%). CONCLUSION: TAE + PCA in patients with T1b or T2 RCC is technically feasible without significant added detriment to renal function. This combined approach may help to reduce hemorrhagic AEs but larger patient cohorts are needed.

Nononcologic Embolization.

The scope of conditions managed by embolization, which was initially used for the treatment of hemorrhage and vascular malformations, is constantly expanding. Apart from oncologic indications, embolization is used to treat a wide range of benign pathology, including uterine fibroids and benign prostatic hyperplasia. While various particulate embolic agents are successfully used for benign embolization, there is growing evidence that unique properties of these may result in different outcomes. This article reviews available evidence comparing various particles used for uterine fibroid embolization and prostate artery embolization. In addition, we provide an overview of periprocedural pharmacology and protocols facilitating same-day discharge for these interventions.

External Validation of the Percutaneous Renal Ablation Complexity Scoring System in Patients Undergoing Percutaneous Cryoablation or Microwave Ablation of Renal Tumors.

PURPOSE: To assess the ability of the Percutaneous Renal Ablation Complexity (P-RAC) scoring system to predict procedural complexity or adverse events (AEs) in adult patients undergoing percutaneous thermal ablation of renal tumors. MATERIALS AND METHODS: A retrospective review of 240 consecutive adult patients who underwent percutaneous thermal renal ablation from 2004 to 2018 was conducted. The P-RAC score was calculated for each renal tumor and procedural complexity recorded. A correlation coefficient was calculated for the P-RAC score and both the number of probes used and procedural duration. Receiver operating characteristic curves assessed the score's ability to predict the use of adjunctive techniques and/or major AEs, classified according to the Society of Interventional Radiology guidelines. RESULTS: For the entire cohort, there was a weak correlation between P-RAC scores and both the number of probes used (r = 0.31; P < .001) and procedural duration (r = 0.18; P = .03). When evaluating only patients treated with microwave ablation (MWA), no correlation between P-RAC scores and either the number of probes (P = .7) used or procedural duration (P = .4) was found. The area under the curve (AUC) for the P-RAC score to predict the use of adjunctive techniques was 0.55 and 0.53 for the entire cohort and MWA group, respectively. The AUC for the P-RAC score to predict major AEs was 0.70, 0.71, and 0.73 for the entire cohort, MWA group, and cryoablation group, respectively. CONCLUSIONS: The P-RAC scoring system is limited in its ability to predict percutaneous thermal renal tumor ablation procedural complexity, especially in patients treated with MWA. The scoring system may have a role in identifying patients at risk of major AEs.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel.

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

Uterine Artery Embolization for Adenomyosis.

Adenomyosis is a benign gynecologic condition of the uterus similar to uterine leiomyoma (fibroids), but with different pathophysiology and prevalence. The treatment algorithms for symptomatic adenomyosis are not as established as for uterine fibroids and other gynecologic conditions. Uterine artery embolization (UAE) is a well-recognized treatment for symptomatic uterine fibroids. This minimally invasive therapy has been likewise effective for symptomatic adenomyosis but with nuances in UAE protocol and outcomes. There is also less quality evidence to garner support for generalized use of the procedure for symptomatic adenomyosis. Many factors contribute to this lack of data, and efforts to clarify the utility of UAE in adenomyosis will need to address a classification system and standardization of technique.

Uterine artery embolization: A review of current concepts.

Uterine artery embolization (UAE) has gained traction as a safe and effective treatment modality for symptomatic uterine leiomyomata since its introduction nearly two decades ago. This review includes an overview of current concepts with regard to patient selection, technique, and outcomes following UAE. Specific topics also include the impact of this procedure on fertility and pregnancy, the emerging role of UAE in the treatment of adenomyosis, and how UAE compares with surgical intervention for the treatment of symptomatic leiomyomata.

Leiomyoma Infarction after Uterine Artery Embolization: Influence of Embolic Agent and Leiomyoma Size and Location on Outcome.

PURPOSE: To study the factors that might impact infarction of individual uterine leiomyomas and total tumor burden after uterine artery embolization (UAE). MATERIALS AND METHODS: This retrospective study included 91 patients (mean age, 44 y [range, 34-54 y]) who underwent UAE with tris-acryl gelatin microspheres (TAGMs) or nonspherical polyvinyl alcohol (PVA) particles. Twenty-one patients were treated with PVA (23%) and 70 were treated with TAGMs (77%). A total of 356 uterine leiomyomas were assessed, with a median uterine volume of 533 cm3 (range, 321-848 cm3). A reader masked to demographic and technical details reviewed contrast-enhanced magnetic resonance images before and 3 months after UAE to estimate the extent of tumor infarction. RESULTS: There was no significant difference in global or individual tumor infarction rate between embolizations with TAGMs and PVA particles (P = .73 and P = .3, respectively). Global infarction was not affected by age (P = .53), race (P = .12), number of leiomyomas (P = .72), or uterine volume (P = .74). Leiomyoma size did not influence individual tumor infarction (P = .41). Leiomyoma location was the sole factor that influenced individual tumor infarction rates, with pedunculated serosal tumors significantly less likely to show complete infarction than transmural tumors (odds ratio, 0.24; P = .01). CONCLUSIONS: Nonspherical PVA particles and TAGMs produce similar rates of uterine leiomyoma infarction. Complete infarction of individual tumors is less likely in serosal and pedunculated serosal tumors.

Benign Metastasizing Leiomyomas Following Myomectomy and Uterine Artery Embolization.

Benign metastasizing leiomyomas (BMLs) are rare sequelae of common uterine leiomyomas and most frequently found in the lungs. Most cases of BMLs occur with a history of prior gynecologic procedures; however, none have yet been reported in association with uterine artery embolization (UAE). This case report highlights the disease course for a 48-yo female with a history of both myomectomy and UAE for uterine fibroids who presented later with bilateral pulmonary BMLs. Though the pathophysiology of BMLs is poorly understood and this case is confounded by prior myomectomy, it does bring into question whether UAE has a role in BML development. Regardless, UAEs have become a routine procedure and interventionalists should be aware of the possibility of BMLs in post-fibroid treatment patient populations.