Outcomes following unilateral uterine artery embolisation.

Uterine artery embolisation has been described as successful only when both arteries are embolised. However, results in patients with one congenitally absent or previously ligated artery are unknown. Women suffering from symptomatic uterine myomata were treated at a university teaching hospital, a community hospital and an outpatient surgery centre. Retrospective review of patient response to embolisation was assessed by chart review and questionnaire. Uterine and dominant fibroid size response was assessed by comparing pre- and post-embolisation ultrasound examinations. This study analysed three patient groups within the general population: those who underwent unilateral embolisation because of technical failure, those who ultimately underwent bilateral embolisation after initial technical failure and those who underwent unilateral embolisation because of an absent uterine artery. 12 patients underwent unilateral embolisation, 4 of whom underwent this procedure because of an absent uterine artery. Three of these four patients had a congenitally absent uterine artery arising from the internal iliac artery and all three experienced successful outcomes. The fourth patient had a previously ligated internal iliac artery and her symptoms worsened after the procedure. Eight patients had unilateral embolisation due to technical failure. Five of these patients underwent a subsequent procedure during which the contralateral uterine artery was embolised. Four of these five patients had successful outcomes and one was lost to follow-up. Another of the eight patients suffered an arterial injury leading to technical failure, and was lost to follow-up. Of the two remaining patients with unilateral technical failure, only one had a successful outcome. This study concluded that patients who undergo unilateral embolisation for technical reasons should be offered a second embolisation procedure shortly after the initial procedure. Patients with a congenitally absent uterine artery may respond with similar success to those who underwent bilateral embolisation. In contrast, the patient with a previously ligated internal iliac artery failed. The numbers in this study are too small for statistical analysis and subsequent studies should be performed to confirm these findings.

Pregnancy following uterine fibroid embolization.

OBJECTIVE: This paper seeks to evaluate the ability to deliver term pregnancies following uterine fibroid embolization, and to identify impediments to pregnancy in the embolization procedure. STUDY DESIGN: Four physicians performed embolization procedures at various facilities. Patients were asked if fertility was an issue prior to embolization. We measured follicle-stimulating hormone levels before and after embolization. Clinical follow-up, six months following embolization was obtained by interview. Patients were questioned regarding attempts to conceive, menstrual history, and subsequent pregnancy. MAIN OUTCOME MEASURES: Complications were calculated upon the entire patient population, whether or not fertility was identified as a goal. Fertility risks from embolization were identified. We measured radiation exposure in a random consecutive group of 50 women undergoing embolization. All patients who conceived were asked the details of the pregnancy. RESULTS: Four hundred women underwent uterine fibroid embolization between 1996 and 1999. One hundred and thirty nine patients stated a desire for fertility after embolization. Of these, 52 were <40 years old. Seventeen pregnancies have been reported in 14 women. Five spontaneous abortions were observed. Ten women have had normal term deliveries and two women are currently pregnant. No perfusion problems, either during the pregnancy or labor, were reported. The average radiation dosage calculated for 50 women undergoing embolization was 14 rads. Four women under 45 years old suffered premature menopause (10/1000). Two women underwent hysterectomy as a complication of embolization (5/1000). CONCLUSION: The risks of infertility following embolization, premature menopause, and hysterectomy are small, as is the radiation exposure during embolization. These risks compare favorably with those associated with myomectomy. Fertility rates appear similar to patients undergoing myomectomy. No problems, either during pregnancy or delivery, have been observed after embolization. The course of pregnancy and delivery was normal after embolization with no maternal or fetal complications reported. These findings confirm results from other centers. Desire for future pregnancy is not a contraindication to fibroid embolization.

Uterine fibroid embolization: nonsurgical treatment for symptomatic fibroids.

BACKGROUND: Earlier studies demonstrated the efficacy of uterine fibroid embolization (UFE). We seek to demonstrate the success of the procedure in a community hospital setting, and we attempt to identify patients likely not to benefit from embolization, if possible, before the procedure. STUDY DESIGN: The study followed all women treated with UFE for menorrhagia or postmenopausal bleeding at a community hospital between 1997 and 1999. Relief of symptoms, ultrasound changes, and complications were documented. Six months after the procedure, analysis was performed on ultrasound and interview data from patients who underwent UFE. A smaller number of patients has been followed for 12 months and were available for the analysis. We examined characteristics of patients and procedures performed in an attempt to identify likely failures of treatment. We calculated complication and failure rates based on the entire group of patients. RESULTS: From 183 patients who applied for UFE, 16 were excluded because ofpathologic conditions found during preembolization evaluation; 167 women had an embolization, 163 were successfully embolized bilaterally, and 4 were embolized unilaterally because of technical failure. Eighty-eight percent of the patients (147 of 167 patients) reported an improvement or stabilization of symptoms 6 months after UFE. Forty-six patients followed for 12 months experienced myoma shrinkage of 37% (a significant shrinkage over 6 months, p < 0.001), and total uterine volume decreased 52%. Analysis of shrinkage data revealed no demographic or procedure variable associated with shrinkage. Six patients underwent hysterectomy (3.5%) after embolization, one as a result of postprocedure infection. Pain in the first 24 hours postprocedure affected almost all patients. Five percent of the patients passed submucous myomata after UFE; all these patients at risk were identified at preembolization hysteroscopy. Four patients experienced premature menopause after embolization early in the study. There were three criteria for failure, of which a patient had to meet only one: hysterectomy, < 10% shrinkage ofmyoma 6 months after UFE, or worsening symptoms after UFE. No variables of age or size of the uterus could be shown to predict failure. Patients who had undergone earlier pelvic surgery were more likely to fail UFE (p = 0.012). CONCLUSIONS: Uterine fibroid embolization, an alternative treatment for myomas, offering low morbidity, can be performed in a community hospital setting. Eighty-eight percent of patients reported improvement or stabilization of symptoms. Total uterine volume decreased an average of 49% at 6 months after embolization. Shrinkage was unaffected by the size of the uterus, myoma, or patient characteristic before UFE. Longterm followup study reveals a significant continuing shrinkage of total uterine volume and myomata at 12 months. There has been no regrowth of fibroids. Earlier surgery was a factor predicting failure of UFE in our series. The risks to future fertility were small.

Uterine artery embolization for the treatment of uterine leiomyomata midterm results.

INTRODUCTION: The authors review their midterm experience with uterine artery embolization for the treatment of uterine fibroids. MATERIALS AND METHODS: Sixty patients were referred for permanent polyvinyl alcohol (PVA) foam particle uterine artery embolization during an 18-month period. Detailed clinical follow-up and ultrasound follow-up were obtained. RESULTS: Bleeding was a presenting symptom in 56 patients and pain was a presenting symptom in 47 patients. All patients underwent a technically successful embolization. One of the patients underwent unilateral embolization. Fifty-nine patients underwent bilateral embolization. Of all patients undergoing bilateral embolization, at last follow-up (mean, 16.3 months), 81% had their uterus and had moderate or better improvement in their symptoms. Ninety-two percent of these patients also had reductions in uterine and dominant fibroid volumes. Overall, the mean uterine and dominant fibroid volume reduction were 42.8% and 48.8%, respectively (mean follow-up, 10.2 months). One infectious complication that necessitated hysterectomy occurred. CONCLUSION: Uterine artery embolization for the treatment of uterine fibroids is a minimally invasive technique with low complication rates and very good clinical efficacy.

Transvaginal saline hysterosonography: characteristics distinguishing malignant and various benign conditions.

OBJECTIVE: The objective of this study is to establish criteria for distinguishing endometrial polyps, submucosal leiomyomas, endometrial hyperplasia, and endometrial carcinoma on saline hysterosonography. MATERIALS AND METHODS: Sixty-three saline hysterosonograms with histologic confirmation were retrospectively analyzed. We found 26 endometrial polyps, 16 submucosal leiomyomas, three endometrial hyperplasias, one abnormal endometrium associated with a sloughed polyp, one pseudopolyp, and three endometrial carcinomas; 15 sonograms revealed no abnormality. In two patients, sonography revealed both polyps and submucosal leiomyomas. The sonographic appearance of these abnormalities was analyzed to define criteria for their diagnosis. RESULTS: Twenty-five of 26 polyps were uniformly echogenic with smooth borders and either had a stalk or formed acute angles with underlying endometrium. Sixteen of 16 submucosal leiomyomas showed heterogeneous echogenicity; however, 13 were sessile and three were pedunculated. Endometrial hyperplasia was manifested by wall thickening in two patients and tiny polypoid excrescences in one patient. In all patients with endometrial carcinoma, the endometrial cavities were poorly distensible despite successful cervical os cannulation. All patients with abnormalities other than endometrial carcinoma had fully distensible uterine cavities. CONCLUSION: Malignant and various benign endometrial conditions may be accurately distinguished on saline hysterosonography. Uniformity of echogenicity distinguished all polyps from submucosal leiomyomas, but the angulation formed with the endometrial wall by the intracavitary mass did not distinguish all polyps from submucosal leiomyomas. Lack of distensibility of the endometrial canal is a potential sign of endometrial carcinoma.

Preliminary experience with uterine artery embolization for uterine fibroids.

PURPOSE: To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for fibroid-related vaginal bleeding and pelvic pain refractory to hormonal therapy and myomectomy. MATERIALS AND METHODS: Eleven patients (aged 27-55 years; mean, 44.2 years; none desiring future pregnancy) with refractory vaginal bleeding and/or chronic pelvic pain related to uterine leiomyomata underwent uterine artery embolization with use of polyvinyl alcohol (PVA) particles. Clinical improvement was assessed by detailed questionnaire at 2-9 months (mean, 5.8 months) after the procedure. Sonographic measurements of the uterus and dominant masses were obtained before and at 2 months after the procedure. RESULTS: All 11 patients underwent technically successful embolization. Eight of nine women who completed the follow-up questionnaire reported noticeable symptomatic improvement, including three women with complete resolution of symptoms. One woman (the only patient undergoing unilateral embolization) exhibited no clinical response. Another patient developed endometritis and pyometra 3 weeks after the procedure, necessitating hysterectomy. Large reductions in uterine volume (average, 40%) and dominant fibroid size (average, 60%-65%) were sonographically demonstrated. CONCLUSION: Uterine artery embolization represents a promising new method of treating fibroid-related menorrhagia and pelvic pain. Further investigation will be required to assess clinical response and durability, identify appropriate candidates, and define the optimal angiographic technique and PVA particle size.

Color Doppler imaging findings in patients with Budd-Chiari syndrome: correlation with venographic findings.

OBJECTIVE: This study was undertaken to evaluate color Doppler imaging findings in patients with Budd-Chiari syndrome and to compare these findings with results of venography. SUBJECTS AND METHODS: In a prospective study, 21 patients with proved Budd-Chiari syndrome had color Doppler imaging. Sonographic evaluations ware performed to detect appropriately directed flow in the hepatic veins, portal vein, and inferior vena cava. Intrahepatic collaterals were characterized when present. Results of color Doppler imaging were compared with those of angiography in 20 patients. Color Doppler images of the hepatic veins were also obtained in a reference group (20 control subjects, 20 patients with hepatomegaly, and 20 patients with cirrhosis). RESULTS: Color Doppler imaging showed abnormalities of anatomy or flow in one or more of the main hepatic veins in all 21 patients with Budd-Chiari syndrome. Commonly observed abnormalities were visualization of a hepatic vein on real-time sonograms that had no flow or retrograde flow on color Doppler sonograms (11 cases) and no visualization of part or all of a hepatic vein on either real-time or color Doppler sonograms (10 cases). When compared with venographic findings (16 patients), findings on color Doppler sonograms could be used to distinguish patent from occluded hepatic veins in all cases. In our reference group, real-time and color Doppler sonograms showed normal hepatic veins in all control subjects. Real-time sonograms clearly showed hepatic veins in 12 of 20 patients with hepatomegaly; color Doppler sonograms showed flow in the hepatic veins in all 20 of these patients. Among 20 patients with cirrhosis, real-time sonograms showed hepatic veins in only seven; color Doppler imaging confirmed patent veins in 17. Intrahepatic collaterals typical of Budd-Chiari syndrome were observed in 10 of 21 patients with the syndrome. The portal vein was assessed by using color Doppler imaging in all 21 patients with Budd-Chiari syndrome; portograms were available for comparison in 10 patients. Findings were consistent in eight; in two cases, the direction of flow was reversed on color Doppler sonograms compared with portograms. For the inferior vena cava, venographic and sonographic findings correlated in 16 of 20 cases. Color Doppler sonograms did not show a caval web in one patient. CONCLUSION: Abnormalities of the hepatic veins, portal veins, and inferior vena cava detected on color Doppler sonograms in patients with Budd-Chiari syndrome correlate well with findings on venograms.(ABSTRACT TRUNCATED AT 400 WORDS)

Sonographic findings after surgical ablation of the endometrium.

OBJECTIVE: Endometrial ablation is a new surgical technique that is an alternative to hysterectomy in women with dysfunctional uterine bleeding. The endometrium is either coagulated or resected in an attempt to render the patient amenorrheic. Because of the newness of the procedure, no report of radiologic findings after endometrial ablation has been published. Accordingly, the sonographic appearance of the uterus after endometrial ablation is described. MATERIALS AND METHODS: Using transvaginal sonography, we examined a select group of 16 women, seven of whom were symptomatic after endometrial ablation. All patients had a preoperative diagnosis of menorrhagia not responsive to conventional hormonal therapy and no evidence of cancer. RESULTS: In the seven symptomatic patients, sonography showed that postoperatively two had hematometra, one had a nonviable intrauterine pregnancy, and four had residual islands of functioning endometrial tissue alone or in combination with hematometra. In nine asymptomatic patients, postoperative sonography showed seven had normal findings except for leiomyomata and two had residual islands of functioning endometrial tissue. CONCLUSION: Sonographic examination of the uterus after endometrial ablation provides a method for evaluating symptomatic patients and for identifying any remaining endometrium that could later become symptomatic.

Color Doppler imaging of the hepatic vasculature.

Duplex sonography added a new dimension to real-time sonographic imaging and can be used to characterize flow dynamics. Unfortunately, duplex sonography also has significant drawbacks, most of which are the result of the limited sampling ability of pulse-gated technology and the inability to provide a global display of Doppler information. Sonographic imaging of intraabdominal vessels has improved markedly with the advent of color Doppler techniques. This article reviews the use of color Doppler sonography in the evaluation of hepatic vessels. The complementary role of Doppler spectral analysis is also considered.

Fetal exposure from endovaginal ultrasound examinations in the first trimester.

Ultrasonic obstetrical examinations during the first trimester are now often performed endovaginally with higher-frequency (5-7.5 MHz) transducers operating closer to the fetus than for transabdominal examinations. To estimate exposure to the fetus, propagation distances were obtained from a retrospective study of 100 normal first-trimester endovaginal B-mode examinations. No significant dependence of attenuation on gestational age was observed. The range of the attenuation estimates was 1.8-10.4 dB. A mean attenuation of 5.0 dB at 5 MHz for an average depth of 2.8 cm resulted in an attenuation coefficient of .36 dB/cm/MHz. Exposure (ISPTA) to the fetus at each gestational week from three ultrasound units was very similar: worst-case values of the 100 cases ranged from 1.2-1.9 mW/cm2, well within the Food and Drug Administration (FDA) guidelines of 94 mW/cm2 for derated focused transducers. Energy density deposited to the anterior surface of the fetus during a typical examination, assuming that the transducer is kept stationary over one area for the entire period of the examination (which is unlikely), ranged from 143-217 mJoules/cm2, within the American Institute of Ultrasound in Medicine (AIUM) recommendations.

A new electronically enhanced biopsy system: value in improving needle-tip visibility during sonographically guided interventional procedures.

Sonographically guided fine-needle biopsy procedures are hampered by poor visibility of the needle tip. This study was performed to evaluate a new system for placing needles under sonographic guidance. The Biosponder needle (Advanced Technology Laboratories, Bothell, WA) incorporates a specialized stylet with a passive sensor at its tip. When an ultrasound pulse is detected by the sensor, an electrical signal is transmitted to the sonographic unit by a battery-powered electronic module connected to the stylet and to the scanner. This signal is converted into a bright, flashing marker on the screen at the precise location of the needle tip. The Biosponder system, which uses 20- or 22-gauge needles, was compared with a 20-gauge Turner needle (Cook, Bloomington, IN) in 18 patients with masses or fluid collections and two patients requiring nephrostomy tube placement. The tip of the Turner needle could not be localized precisely in any patient. The shaft of the Turner needle was seen clearly in 13 patients, poorly in three, and was not visualized at all in four patients. Excluding four instances of mechanical failure, the Biosponder system allowed precise localization of the needle tip in every patient and was consistently rated as easier to use than the Turner needle. We conclude that the Biosponder needle, with its precise tip localization and ease of use, is a valuable tool for sonographically guided needle placement.

Endoluminal catheter-assisted transcervical US of the human embryo. Work in progress.

To enhance visualization of anatomic structures of the human embryo, the authors used a commercially available catheter-based ultrasound (US) transducer (12.5 MHz) introduced through the cervix and into the endometrial cavity of seven women about to undergo voluntary termination of first-trimester pregnancy. The authors term this technique endoluminal catheter-assisted transcervical (ELCAT) sonography. In none of the patients did the US catheter rupture the fluid-filled chorionic/amniotic cavity. The duration of pregnancy ranged from 5.2 to 10.0 menstrual weeks. The most prominent anatomic structures visualized were the heart and neural tube. As an investigational technique, ELCAT US can be used to image anatomic structures of the developing human embryo.

Detection of renal stones with real-time sonography: effect of transducers and scanning parameters.

Three experiments with a variety of transducers and scanning parameters were designed to investigate if renal stones could be detected with greater certainty by using particular transducers or scanning parameters. First, the lateral resolution, derived from the -6-dB size of the beam profile, was measured at various depths for five transducers commonly used for renal sonography. Second, an in vitro test object was constructed from bovine liver, porcine kidneys, and two renal calculi to access gray-scale map effects on shadow visibility before and after storage in the digital scan converter. The third experiment combined 15 lithotripsy patients with known renal stones with 16 patients in whom the results of renal sonography and other radiographic procedures suggested renal calculi. The group of 15 patients was scanned several times with the transducers and gray-scale maps studied earlier, and the group of 16 patients was scanned only with one transducer and one gray-scale map. On radiographs, 12 of the 16 patients did not have renal calculi. Sonograms of the test object showed that low-contrast images were best for detection of posterior shadows. Three radiologists interpreted the 31 sonograms with a sensitivity of 81% and a specificity of 86% for detecting renal stones. For the 15 cases of renal stones scanned with a variety of transducers, the three radiologists found that annular-array transducers depicted stone shadowing with less ambiguity than mechanical sector transducers did 81% of the time.

Diagnosis of portal vein thrombosis: value of color Doppler imaging.

This study was undertaken to determine the accuracy of color Doppler imaging in the diagnosis of portal vein thrombosis. Two hundred fifteen patients were studied with color Doppler imaging to determine patency of the main portal vein. Sonographic findings were confirmed in 75 patients, aged 19 to 66 years. Correlation with angiography was obtained in 13 patients, and surgical correlation was obtained in the remaining 62. Nine patients had portal vein thrombosis on the basis of these gold standards. Sonograms were classified as showing either patency or thrombosis, depending on the ability to show color flow within the main portal vein. Agreement between sonography and angiography or surgery was found in 69 patients (61 patent, eight thrombosed). One patient with a patent portal vein at sonography was found to have a thrombosed vessel at surgery, whereas five patients without portal venous flow at sonography had patent vessels at angiography (one patient) or surgery (four patients). Overall sensitivity and specificity for detection of portal vein thrombosis were 89% and 92%, with an accuracy of 92%, a false-negative rate of 0.11, a negative predictive value of 0.98, and a positive predictive value of 0.62. We postulate that the majority of errors in our study occurred in vessels that, although patent, had only sluggish flow, which could not be resolved because of technical limitations. We conclude that color Doppler imaging is a valuable screening procedure for the assessment of portal vein patency. If the sonogram shows a patent portal vein, no further studies are required. However, a lack of demonstrable flow does not always indicate thrombosis, and other imaging studies should be performed for confirmation.

The pulsatile portal vein in cases of congestive heart failure: correlation of duplex Doppler findings with right atrial pressures.

To better understand portal vein pulsatility in congestive heart failure, the authors compared portal vein spectral patterns to right atrial pressures measured with a Swan-Ganz catheter in 17 adult patients suspected of having congestive heart failure. Portal vein pulsatility was also evaluated in 17 healthy adults. A pulsatility score (scale, 1-5) based on a ratio of minimum to peak portal vein velocity was assigned. A score of 1 indicated continuous, monophasic flow, while a score of 5 indicated that flow reversal was observed with each cardiac cycle. All 17 healthy volunteers had portal vein pulsatility scores of 2 or less. Among the 17 patients suspected of having congestive heart failure, seven had normal right atrial pressure (less than 10 mm Hg) and pulsatility scores of 2 or less. Among the 10 patients with a right atrial pressure of 10 mm Hg or greater, six had pulsatility scores of 3 or greater (sensitivity, 60%; specificity, 100%). Greater than 50% of the variation in portal vein score is explained by changes in right atrial pressure. Review of echocardiograms in 13 of 17 patients showed no significant correlation between the degree of tricuspid regurgitation and portal vein score. Portal vein pulsatility is a sign of elevated systemic venous pressure.