An Academic Tertiary Referral Center's Experience with a Vascular Surgery-Based Uterine Artery Embolization Program.

BACKGROUND: Despite growing endovascular experience within the vascular surgery community, some catheter-based interventions-such as uterine artery embolization (UAE)-remain outside the clinical scope of most vascular surgeons, owing in part to established referral patterns and limited awareness among referring colleagues. We present our experience with a vascular surgery-based, multidisciplinary UAE program at an academic tertiary referral center. METHODS: In a collaborative effort between vascular surgeons and gynecologists, a pelvic vascular disease program has been established to provide palliative, prophylactic, and therapeutic embolizations including, but not limited to, UAE. For UAE, inclusion criteria are women over the age of 18 years with symptomatic uterine fibroids demonstrated on magnetic resonance imaging and a negative endometrial biopsy. Exclusion criteria are desire for future pregnancy and previous embolization(s). Technique and perioperative protocol is presented. Data including symptom resolution, reintervention rates, and complications were prospectively gathered and retrospectively reviewed. RESULTS: Over an 18-month period, 30 patients with symptomatic fibroids were referred for potential UAE. Five patients were excluded because of uncertainty about future pregnancy wishes (4) and prior embolization (1). Twenty-four bilateral and 2 unilateral UAEs were performed (mean age, 46.3 years [range 28-53 years]). Presenting symptoms were pelvic and abdominal pain (25), cramps (25), menorrhagia (25), dysmenorrhea (25), urinary frequency (12), and dyspareunia (5). Technical success, defined as successful microcatheterization of uterine arteries and delivery of a particulate liquid embolic agent (embospheres, 500-700 microns), was 100%. There were no perioperative or delayed complications. Twenty-one patients (87.5%) reported complete symptomatic relief without further intervention at the time of last follow-up. Three patients (12.5%) reported pain relief but had persistent vaginal bleeding requiring hysterectomy 12 months after UAE. All patients underwent a 23-hr observation postoperatively for pain control. Mean follow-up was 7.4 months (1-23 months) and included pelvic ultrasound assessment of fibroid size at 1, 3, and 6 months after UAE and annually thereafter. One patient was lost to follow-up. Fibroid shrinkage was noted in all patients. Given the willingness and capability to work-up, admit, treat, and follow-up patients, vascular surgery was deemed the preferred service for UAE by the referring gynecologists. CONCLUSION: Within the framework of a collaborative, multidisciplinary program, vascular surgery can play a prominent role in providing safe and effective UAE.

Direct stick embolization of extremity arteriovenous malformations with ethylene vinyl alcohol copolymer.

Direct stick embolization (DSE) of high-flow peripheral arteriovenous malformations (AVMs) has previously been reported using n-butyl cyanoacrylate and ethanol. The use of ethylene vinyl alcohol copolymer (Onyx; Covidien, Plymouth, Minn) through this delivery route has been extremely limited, particularly in the peripheral interventional realm, owing to concerns about technique and conduit for delivery, skin discoloration, and ulceration. We describe three patients with relatively focal, symptomatic, congenital high-flow AVMs of the upper and lower extremity treated successfully by multifaceted approaches including transvenous coil embolization of the nidus venous outflow, transarterial embolization, and DSE of the AVM nidus with Onyx. Successful delivery of Onyx into the AVM nidus was achieved without nontarget embolization. Sustained symptomatic relief without recurrence or associated complications was achieved at 1 month, 3 months, and 6 months of follow-up. Nidus embolization is a key technical maneuver for optimal treatment of high-flow AVMs, although it is not always easily achievable by the transarterial route in more extensive, convoluted angioarchitectural varieties. With appropriate technical considerations and precautionary measures, Onyx can be safely and effectively delivered through DSE into the AVM nidus with satisfactory short-term and midterm clinical outcomes. This maneuver expands the armamentarium of the treating vascular surgeon facing complicated peripheral AVMs.