Transbrachial approach to the treatment of uterine leiomyomas with embolization of the uterine arteries: a preliminary technical experience.

INTRODUCTION: Uterine leiomyomas are benign tumours; recently they have been managed with embolization of the uterine arteries. We analysed the technical feasibility, safety and efficacy of this treatment performed via an innovative transbrachial approach, rather than the traditional transfemoral approach. MATERIALS AND METHODS: Between 2009 and 2013, 115 patients were treated with embolization of the uterine arteries for one or more symptomatic leiomyomas. In 20 of these 115 patients, a transbrachial approach was used. Under ultrasound guidance, the left brachial artery was punctured. After having placed the tip of the angiography catheter at the level of L4 to check the aortic bifurcation, the uterine arteries were catheterised and embolized with calibrated particles. Data concerning exposure to radiation and the duration of the intervention were recorded for comparison between the two groups of subjects. Clinical controls and magnetic resonance imaging were complemented with echo-colour Doppler of the brachial artery to confirm the integrity and function of the vessel. RESULTS: The uterine arteries were catheterised easily in a mean time of 25″, compared to 72″ using the femoral approach. As far as exposure to radiation was concerned, the mean fluoroscopy time for the femoral approach was 21.7' [range 14.4-42.7'] compared to 17.6' [range 7.7-25.5'] for the transbrachial approach. The time of occupation of the angiography suite was 118' (range 95-155') with the femoral approach, compared to 92' (range 65-123') with the transbrachial approach. No immediate complications involving the brachial artery were recorded. DISCUSSION: In the treatment of symptomatic uterine fibromas, embolization of the uterine arteries performed via a transbrachial approach was shown to be safe and technically valid with regard to reducing the overall time of the intervention, ease of selective catheterisation, and shorter times spent in hospital, as well as being better accepted by patients.

Endovascular management of the rectus muscle hematoma.

PURPOSE: Non-traumatic spontaneous hematoma of the rectus abdominal muscle is not considered a critical condition. Nevertheless, it can be a serious complication in some patients due to continuous and/or consistent bleeding. The most frequent cause of spontaneous rectus muscle hematoma is the anticoagulation therapy. The natural history of rectus muscle hematoma usually leads to a positive outcome and can be spontaneously self-limited only by conservative therapy. Nevertheless, in some patients, despite a correct and early medical therapy, the continuous bleeding requests a more radical handling. Up to now, the surgical hematoma evacuation and the bonding of blood vessels were considered the most appropriate treatment, while at present, the percutaneous management by means of selective catheters and embolization of the bleeding vessel is considered to be the most used option. Our purpose is to report our experience in the endovascular spontaneous rectus muscle bleeding treatment in the elderly patients. MATERIALS AND METHODS: From the data base and medical reports of the hospital, we selected 144 medical reports. We focused on those cases that showed the following criteria: patients with rectus muscle hematoma undergoing anticoagulation therapy and/or non-traumatic spontaneous hematoma and with persistent bleeding revealed on CT examination despite a pharmacological treatment aimed to timely reverse coagulopathy. These criteria were found in 18 patients: 15 females and 3 males, with a median age of 73 (range 64-81). In all patients, the diagnosis had been confirmed by an abdominal CT in emergency setting, performed before and after contrast medium intravenous administration. Because of clinical conditions, all patients had been moved on the angiographic room for diagnostic arteriography and embolization. The criteria for this treatment were hemodynamic instability and the continuous bleeding despite the correct medical therapy. RESULTS: CT imaging detected rectus muscle hematoma in 18/18 patients and active bleeding in 7/18 patients. Selective catheterization was applied to all 18 patients; arteriographic study confirmed the information of the CT study in all of the seven patients. The inferior epigastric artery was the main cause of the bleeding in all 18 patients. In 14 patients, one single vessel was responsible for the bleeding, while in the other four patients, more than one vessel were involved: In two patients, we also found the involvement of the superior epigastric artery; while the other two patients showed also the involvement of the deep iliac circumflex artery. The material for embolization was compatible coils with micro-catheters in 17/18 patients, and glue for 1/18 patient. CONCLUSIONS: Patients with large rectus muscle hematoma, which have not yet recovered with conservative therapy, should then consider undergoing endovascular treatment. This procedure is highly recommended in patients with other coexisting pathologies that could eventually lead to a fatal outcome. It is difficult to determine when surgery is necessary when there is very poor data provided by scientific literature review, so the decision to use surgery can be suggested when embolization is unsuccessful or when it is necessary to evacuate a complex huge fluid mass in peritoneal cavity.

Diagnosis of right-sided varicocele: a retrospective comparative study between clinical examination, Doppler findings, US imaging and vascular anatomy at phlebography.

Historically varicocele is diagnosed almost exclusively on the left side. The introduction of new imaging techniques has allowed the identification and characterization of right varicocele. This study aims to compare the diagnostic accuracy of various imaging techniques to data obtained using phlebography in the diagnosis of right varicocele. Patients treated for isolated right varicocele between 1992 and 2010 were retrospectively identified. Data from clinical examination, Doppler-USS, Color-Doppler-USS and Retrograde Phlebography were collected for each patient. 133 out of 4305 patients (3.1%) presented with an isolated right varicocele. 34 of these patients (25.6%) presented with palpable right varicocele. Doppler-USS identified various degrees of type I right venous reflux in 90 patients (67.7%). Phlebography showed venous reflux in all the patients (133), although with variability in terms of internal spermatic vein anatomy. Right varicocele is characterized by predictable anatomic features. Identification and characterization of these features is useful in guiding percutaneous treatment, allowing to optimize radiological display and reducing failure rate.

Acute hepatocellular and cholestatic injury during therapy with hydrochlorothiazide - clinicohistopathologic findings: a case report.

INTRODUCTION: Hydrochlorothiazide and thiazide-like diuretics are considered first-line drugs for initial therapy in uncomplicated arterial hypertension. Acute cholecystitis is a well-known complication during treatment with thiazide, and these drugs are also reported to be followed by pronounced insulin resistance. CASE PRESENTATION: We describe a case of acute cholestatic hepatitis in a 68-year-old Caucasian man who was receiving olmesartan and hydrochlorothiazide for arterial hypertension. From the clinical and histologic findings, we diagnosed him as having hepatocellular-cholestatic injury and a disorder of glucose metabolism in the liver. To the best of our knowledge, no histopathologic description of hydrochlorothiazide hepatotoxicity has previously been documented in the literature. CONCLUSION: In the differential diagnosis of cholestatic hepatitis, clinicians should be aware of the possibility of liver damage in patients receiving hydrochlorothiazide therapy.

Endovascular treatment of benign superior vena cava syndrome: venographic patterns and implications for treatment.

PURPOSE: We report our experience with the percutaneous treatment of superior vena cava syndromes of benign etiology. MATERIALS AND METHODS: From August 1994 to August 2003 a total of 14 superior vena cava syndromes of benign origin were treated. Previous use of a central venous catheter pending the development of a peripheral arteriovenous fistula for dialysis was believed to be the cause of the obstruction of the superior vena cava in 11 patients. In 2 other cases the cause was attributed to post-radiation mediastinal fibrosis and, in one case, to a previously implanted pacemaker. The superior vena cava syndrome was confirmed by venography. After negotiating the obstruction, a self-expanding stent was selected based on the CT and venographic data. At the end of the procedure, technical success was confirmed by venography, and haemodynamic success by pressure measurements. The follow-up allowed the assessment of the clinical success of the procedure. RESULTS: Technical success was achieved in 13 patients (92.8%); in one case the obstruction could not be negotiated with the wire guide, so the patient was referred for surgery. One self-expanding stent proved sufficient to resolve the central venous obstruction and restore superior vena cava diameter in all cases but one. In one young woman, whose central obstruction was resolved with PTA, was unable to complete the procedure with deployment of a self-expanding stent owing to a supervening asthma attack that could not be treated with the commonly-used drugs. No complications related to the procedure were reported. The symptoms cleared up within 2 weeks, and haemodynamic improvements were already seen within minutes of stent deployment. CONCLUSIONS: Percutaneous treatment is a valuable alternative to surgery as it is able to restore haemodynamic parameters and resolve the clinical picture, ensuring longer functionality to arteriovenous fistulae and an improved quality of life.

Post-traumatic high flow priapism percutaneously treated with transcatheter embolisation.

PURPOSE: The aim of this paper is to present our experience in the percutaneous management of high-flow priapism with transcatheter embolisation and gelfoam. MATERIALS AND METHODS: We present three clinical cases in which an acute trauma caused the development of high-flow priapism. After differing initial management, all cases underwent arteriography, followed by demonstration of the arterial-lacunar fistula and embolisation with gelfoam. RESULTS: Near immediate detumescence after the procedure confirmed the success of embolisation, which was supported by clinical and instrumental follow-up. DISCUSSION: In high-flow priapism, the best therapeutic solution remains transcatheter arterial embolisation, with ultra-selective catheterisation by microcatheter and embolisation of the pudendal artery only, which is responsible for the post-traumatic arterial-lacunar fistula. This manoeuvre is not always technically easy, and requires experience and remarkable dexterity. Technical failure is always possible owing to the spasm of a peripheral arteriole that cannot be resolved with papaverine, and to the possible rehabilitation by the downstream contralateral circulation. Furthermore, the apprehension of the operator carrying out the procedure in this anatomical context may make the immediate result seem satisfactory, even if it is not optimal. All these considerations stress the need for a rigorous clinical and instrumental follow-up to guide later diagnostic and therapeutic choices.

[Percutaneous management of hemorrhages in pelvic fractures].

PURPOSE: To report our experience in the control of haemorrhage with the transcatheter embolisation technique. MATERIALS AND METHODS: Between 1999-2001, we treated 56 patients with important pelvic trauma. Forty-two were victims of car accidents and 14 of falls from great altitudes. Twenty presented acute symptoms due to blunt pelvic trauma, with massive bleeding, not treatable by drugs and blood transfusion. Diagnosis of pelvic haemorrhage was made with CT. When high-flow haemorrhage was found, the patient was referred for angiography. Embolisation was achieved after a diagnostic arteriography, with bilateral transfemoral approach and selective catheterisation of the internal iliac arteries. RESULTS: Technical success was achieved in 100% of cases: all the haemorragic sites were found and embolised. In only one patient with severe shock was it impossible to locate the site of contrast material extravasation on the first day; the patient was successfully treated on the second day with improvement of the clinical conditions. The obturator artery was involved in five cases, the gluteal artery in eleven. In eighteen patients, use of an angiographic catheter was sufficient to treat the haemorragic sites. Percutaneous control of the haemorrhage was obtained by using Gelfoam, Ivalon and coils. CONCLUSIONS: Percutaneous haemorrhage control is safe and effective, and not as costly or dangerous as the surgical option. We regard it as the treatment of choice in multiple trauma patients with important and high-flow pelvic haemorrhage.

[A transbranchial approach for the percutaneous therapy of pediatric varicocele].

PURPOSE: Male varicocele affects children with the same incidence as it does adults. The association between asymptomatic idiopathic varicocele and male infertility and the poor recovery of testicular function after varicocele repair in adulthood have called for noninvasive clinical and instrumental diagnosis and increasingly early treatment. The department of Pediatric Surgery at our Hospital has screened schoolchildren for the early diagnosis and treatment of childhood varicocele. Our Vascular and Interventional Radiology department has proposed percutaneous treatment for varicocele correction. We report our 10-year experience with percutaneous sclerotherapy of pediatric varicocele with a retrograde transbranchial approach. MATERIALS AND METHODS: From a screening programme involving schools 467 boys were selected who were positive for idiopathic varicocele at clinical examination and at Doppler CW, at rest and during Valsalva manoeuvre. Patients with grade III, or symptomatic grade II varicocele, testicular hypotrophy, or with a dilation of the testicular veins greater than 2.2 mm at baseline were referred for percutaneous treatment. Percutaneous treatment was performed with a transbrachial approach in the basilic vein. After searching for incontinence of the internal right spermatic vein, left renal phlebography was performed in order to identify any incontinence of the left spermatic vein. This vein was then selectively catheterised to perform sclerosis. Tungsten coil embolisation was also performed over a number of years. Follow-up consisted of clinical examination, Doppler CW, Doppler US, or colour Doppler US performed at 3, 6, and 12 months. RESULTS: The radiological procedure was only diagnostic in 78 cases (16.7%). Basilic vein spasm and collaterally-supplied varicocele forced us to discontinue the procedure. The use of materials with smaller diameters and the professional development of the radiological team helped improve the catheterisation rate with time. Using the transbrachial approach alone a total of 287 left-sided, 15 right-sided and 52 bilateral varicoceles were treated. Whereas in two cases of bilateral varicocele a dissection at the origin of both spermatic veins prevented the use of sclerotherapy--though the patients were found to be cured at follow-up with Doppler US--on the left the procedures were continued with a transfemoral approach due to difficulties with the transbrachial catheterisation. As for the left-sided varicoceles, sclerosis were performed in 230 procedures, whereas sclerosis and embolisation on 87 patients. The success rate was 92% for sclerosis, and 86% for sclerosis and embolisation. No major complications were observed. DISCUSSION: Percutaneous treatment is a minimally invasive and relatively non-traumatic interventional radiology procedure, able to confirm the presence of varicocele, accurately map the venous system and allow selective therapy. Our experience with 467 patients over 10 years has allowed us to compare two therapeutic options: sclerosis and sclerosis combined with embolisation. CONCLUSIONS: Percutaneous treatment of varicocele with the transbrachial approach proved to be a safe, effective, inexpensive, and minimally invasive procedure. It can be suggested as the first therapeutic option for varicocele correction, especially for boys and for bilateral forms.

A therapeutic alternative in the treatment of epididymal cysts: percutaneous sclerotherapy.

PURPOSE: Epididymal cysts are benign structures commonly seen during urological or ultrasound testicular examinations. They are treated only if symptomatic. Surgery is the standard treatment, although it carries a high risk of complications. We report our experience with sclerotherapy of epididymal cysts with sonographic assistance, and present an analysis of costs. MATERIALS AND METHODS: Between January 1999 and December 2000 we examined 48 epididymal cysts in 45 patients during ultrasound examinations. Except one, all of the patients were symptomatic. We decided to treat 25 symptomatic cysts that were more than 5 cm. in diameter. All of the patients refused surgery as they knew of the existence of the percutaneous method. The procedures were performed on a out-patient basis with ultrasound assistance and using 3% Polidocanol for sclerosis. Follow-up was at 3/6 and 12 months after treatment. If we found persistence of symptoms and/or a cyst was more than 5 cm of diameter, a second session was proposed. RESULTS: Twenty-five epididymal cysts were treated, with a technical success of 100%. Mean fluid evacuation was 36 ml; mean sclerosing agent injected was 4.5 ml. There were no complications. After 3/6 months 17/25 patients were free of symptoms (68%) and the cysts had disappeared in 15 of them (60%). After the repeat procedure, performed on only 4 patients, the number of symptom-free patients was 21/25 (84%). DISCUSSION: Epididymal cysts are often solitary cystic fluid collections that are occasionally reported during physical or ultrasound urological clinical examinations. They present as painless testicular enlargements on palpation and are echo-free at ultrasound examination. Percutaneous sclerotherapy has gained wide acceptance in the therapeutic handling of other pathologies and it appears as an ideal solution for this benign clinical condition of the superficial structures. Polidocanol, widely used on varicose vein therapies for its local anaesthetic properties, is the ideal sclerosing agent for superficial and delicate structures, such as epididymal cysts. The results of the present study have shown that symptomatic cysts may be cured in 84% of cases without complications and with low costs. CONCLUSIONS: Percutaneous sclerotherapy is a valid therapeutic alternative to surgery in the management of epididymal cysts: it is safe, effective, free of complications, less costly and shows good results in the follow-up.

Analysis of radiation doses in the percutaneous treatment of varicocele in adolescents.

PURPOSE: Varicocele is a common clinical condition that affects 15% of the male population and is an important cause of male infertility. Fluoroscopy-guided percutaneous treatment with retrograde sclerosis is a good alternative to surgery. We report our experience in calculating the total radiation dose to patient and the associated risk. MATERIALS AND METHODS: Our study was performed on 67 patients undergoing percutaneous treatment of varicocele with transbrachial approach and retrograde sclerosis. Thirteen dosimeters with two TLD detectors were positioned on the patients' skin. Calculation of the Entrance Surface Dose and application of appropriate transmission coefficients of the depth-dose allowed us to determine the Equivalent Doses for the single organs. Similar studies were conducted during plain abdominal x-ray and urography for comparative purposes. RESULTS: The mean effective dose during percutaneous treatment of varicocele was 18 mSv, whereas the dose for abdominal x-ray was 1.31 mSv and that for urography was 4.6 mSv. DISCUSSION AND CONCLUSIONS: Examinations involving the use of x-rays have been estimated to contribute to half of all the radiation absorbed by the population, and the number of both diagnostic examinations and interventional procedures is steadily rising. Radiation exposure, especially in children, requires special consideration. Percutaneous treatment of varicocele is a valuable alternative to surgery, not least because of reduced exposure. The use of specially-built lead coats and the creation of regional referral centres employing specialised staff are two possible measures that could further reduce radiation doses and dispel concerns about this procedure.

Optional vena cava filters: preliminary experience with a new vena cava filter.

PURPOSE: To prevent pulmonary embolism, some clinical situations only need a vena cava filter for several days, without the inconveniences of temporary vena cava filters in the short-medium term and without the drawbacks of permanent ones in the long term. We report our initial experience with a new definitive vena cava filter, easy to retrieve when it becomes unnecessary. MATERIAL AND METHODS: From the beginning of January 1999 to December 2001, 18 ALN vena cava filters were deployed. The approach used was transbrachial in ten patients, transjugular in seven, and transfemoral in the others. The indications were pelvic trauma in eleven patients, hip replacement in three; four filters were "prophylactically" placed before surgery in patients at high risk of thromboembolic disease (three with ileal or femoral or ileo-femoral thrombosis, and one without clinically manifest thromboembolic disease). Optional vena cava filters were evaluated for malpositioning, caval perforation, filter migration, acute caval thrombosis or access site thrombosis. Seven optional vena cava filters were retrieved. CT was performed before retrieving the vena cava filters to document the absence of thrombi inside the filters. The transjugular ap-proach was used to retrieve the filters. RESULTS: Technical success was achieved in all patients. No complications were encountered during the procedure; no migration or rupture of the filters was detected during the follow-up. No thrombosis of the vena cava or at the insertion site was encountered. The median retrieval time for the filters was 12': only the transfemoral filters required 15' of fluoroscopy. The median permanence was 63 days. No thrombi were found inside the filters. DISCUSSION: A definitive vena cava filter, easy to retrieve when it becomes unnecessary, is the ideal device in many clinical conditions: young subjects with pelvic fractures orthopaedic and gynaecologic interventions.

Percutaneous treatment of pelvic congestion syndrome.

INTRODUCTION: Pelvic congestion syndrome and chronic pelvic pain are enigmatic clinical conditions that may have considerable impact on the social and relational life of women. Patients usually complain of lower abdominal pain that has lasted for more than six months, is intermittent or continuous, and may become worse during menses or after a hard day's work. Sometimes the pain is accompanied by dyspareunia, urinary urgency or constipation. The traditional treatment of pelvic congestion syndrome has included both medical (analgesics, hormones) and surgical approaches (hysterectomy, ovarian vein ligation). Recently, percutaneous transcatheter embolization has also been proposed. We report our experience with the percutaneous management of pelvic congestion syndrome, using the transbrachial approach and sclerosis alone. MATERIAL AND METHODS: Between 1996 and 2001, 33 women underwent percutaneous treatment for pelvic congestion syndrome at our department. All the women had chronic pelvic pain which was continuous in 69%; 20 patients had dyspareunia, whereas 8 had urinary urgency; 72% took analgesics on a regular basis. All the patients underwent percutaneous treatment of pelvic congestion syndrome on a outpatient basis in a radiological suite, after receiving local anaesthesia. Sclerosis was performed with 3% sodium tetradecyl sulfate. Follow-up consisted of a questionnaire at one month and gynaecological and ultrasound examinations at 6/12 months. RESULTS: The pre-procedural ultrasound examination had revealed a mean diameter of 4.5 mm for the right ovarian vein and of 6.3 mm for the left. We found one pelvic congestion syndrome on the right, 11 on the left and 21 bilaterally. At the one-month follow-up, chronic pelvic pain was present in 13 patients (39%); the pain was continuous in three and intermittent in ten. At the follow-up after 6/12 months the symptoms were unchanged. Ultrasound revealed a reduction in periovarian varicosities, recording a mean diameter of 3.19 mm on the right and 4.5 mm on the left. Symptoms persisted in women with pelvic varicosities measuring over 5 mm at ultrasound. CONCLUSIONS: Pelvic congestion syndrome and chronic pelvic pain that do not respond to medical therapy can be resolved by percutaneous management. Less expensive than surgery, this therapeutic option is safe, effective, minimally invasive and capable of restoring patients to normal function. We propose the transbrachial approach as the first-choice treatment for bilateral pelvic congestion syndrome.