Outcomes of tracheobronchial stent placement for benign disease.

PURPOSE: To retrospectively determine long-term outcomes in patients who have undergone tracheobronchial stent placement for benign diseases. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this retrospective HIPAA-compliant study, with waiver of informed consent. Forty patients (22 female, 18 male; mean age, 52.0 years) who were treated with metallic airway stents for benign stenosis were identified from an interventional radiology database. Causes of airway stenosis included transplant stricture (n = 13), tracheal tube injury (n = 10), inflammation (n = 6), tracheobronchomalacia (n = 4), infection (n = 3), and extrinsic compression (n = 4). Follow-up, which ranged from 6 to 2473 days, was performed by means of chart review for deceased patients and by means of clinical visit or telephone interview for surviving patients. Survival, primary patency, and assisted patency were estimated by using the Kaplan-Meier product limits method. RESULTS: Initial technical success was achieved in all cases. Symptomatic improvement was present in 39 of 40 cases. At review, 15 patients were alive and had clinical improvement, 18 had died of comorbid causes, one had died of uncertain causes, three had undergone subsequent airway surgery, two had undergone airway stent retrieval, and one was lost to follow-up. Survival at 1, 2, 3, 4, 5, and 6 years was 79%, 76%, 51%, 47%, 38%, and 23%, respectively. Loss of primary patency was most rapid during the 1st year. With repeat intervention, assisted patency was 90% at 6.8 years. CONCLUSION: Attrition of tracheobronchial stent patency is most rapid during the 1st year, and a high rate of long-term patency can be achieved with secondary interventions. Metallic airway stents are well-tolerated and useful adjuncts for management of select benign tracheobronchial stenoses.

Percutaneous salvage of a failing rex shunt.

Creation of a mesenterico-left portal vein (PV) shunt with use of autologous internal jugular vein (ie, Rex shunt) is a surgical option for the treatment of symptomatic extrahepatic PV occlusion. Herein a patient is described who underwent angioplasty and stent placement across a shunt stenosis by ultrasound (US)--guided percutaneous transhepatic portal access. Follow-up US has demonstrated continued shunt patency.

Inferior vena cava thrombosis after transjugular intrahepatic portosystemic shunt revision with a covered stent.

A 42-year-old woman who had undergone multiple revisions of a bare-stent transjugular intrahepatic portosystemic shunt was treated for in-stent stenosis by insertion of a polytetrafluoroethylene (PTFE)-covered stent. Immediately after revision with the covered stent, she developed inferior vena cava (IVC) thrombosis. The potential causes and implications of this complication are discussed.

Postoperative evaluation of complex aortovisceral and aortorenal reconstructions by magnetic resonance angiography.

RATIONALE AND OBJECTIVES: To assess the ability of magnetic resonance angiography (MRA) to evaluate complex vascular bypass reconstructions of the abdominal aorta and its major branches in the postoperative period. MATERIALS AND METHODS: Thirteen patients with bypass grafts connecting the aorta to visceral, renal, and lower limb inflow vessels were evaluated with MRA. Three of these patients were also studied with digital subtraction angiography soon after MRA was completed. MRA was evaluated for its ability to detect the grafts and to determine the degree of stenosis in the graft conduit or at the anastomoses to native vessels. RESULTS: Detection of graft conduits and anastomotic sites by MRA was 100% and 99%, respectively. Comparison with digital subtraction angiography in a subset of the patients showed a 100% agreement between the two modalities in their description of stenotic disease in graft conduits and 95% agreement in stenosis characterization at graft anastomotic sites. CONCLUSION: MRA of complex aortic reconstructions with bypass grafts to its major abdominal branches arteries accurately describes the resulting complicated vascular anatomy and likely has a high degree of correlation to digital subtraction angiography in describing the disease within the bypass grafts.

Massive vaginal hemorrhage after uterine fibroid embolization.

A 48-year-old woman underwent uterine fibroid embolization (UFE) for menorrhagia. One-month after the procedure she developed massive vaginal bleeding and required an emergency hysterectomy. Pathologic evaluation of the uterus revealed ulceration of the endometrium overlying the necrotic fibroid. Physicians performing UFE should be aware of this rare but potentially life-threatening complication.

Coil embolization of a tuboovarian anastomosis before uterine artery embolization to prevent nontarget particle embolization of the ovary.

Uterine artery embolization (UAE) is being used more frequently as a primary treatment for uterine leiomyoma. Performing UAE in women who desire future fertility is controversial because of the risks of premature menopause and the undetermined effects on pregnancy. The etiology of ovarian failure after UAE is not yet clearly defined, but one of the leading possibilities is nontarget embolization of the ovaries. In this case report, the authors describe a technique of selective coil embolization of a uterine artery-to-ovarian artery communication before UAE performed specifically to protect the ovary from nontarget embolization.

Experimental renal artery embolization in a combined MR imaging/angiographic unit.

PURPOSE: The purpose of this study was to use a combined x-ray angiography and MR imaging (XMR) system to manipulate intraarterial catheters and monitor the deposition of gadolinium (Gd)-impregnated embolic microspheres in vivo in a canine kidney model. MATERIALS AND METHODS: Seven anesthetized dogs (18-28 kg) were studied. The renal arteries were catheterized under fluoroscopic guidance. Renal blood flow rates were assessed with velocity-encoded cine MR imaging before and after renal artery embolization with Gd-impregnated microspheres (300-500 and 500-700 micro m in size). The particles were injected in vivo into 14 canine renal arteries under fast dynamic T1-weighted MR imaging guidance at one frame per second. Postembolic microsphere distributions were assessed with MR imaging and digital subtraction angiography (DSA). RESULTS: Gd-impregnated microsphere injection into the renal arteries was successful in all animals. Renal enhancement due to the deposition of the particles persisted for at least 1 hour after the injection. The distribution of MR signal enhancement in the kidneys differed for the smaller versus the larger microspheres. The 300-500- micro m microspheres deposited preferentially in the outer cortical regions, whereas the 500-700- micro m microspheres preferentially deposited in the medulla and inner cortex. Renal blood flow was significantly reduced after the administration of both the 300-500- micro m microspheres (from 3.9 to 1.0 mL/min/g) and the 500-700- micro m microspheres (from 3.5 to 0.2 mL/min/g). CONCLUSION: MR imaging permits real-time guidance of arterial embolization with Gd-impregnated microspheres.

Reversal of flow in the ovarian artery during uterine artery embolization.

Uterine artery embolization (UAE) is gaining increasing recognition as an effective treatment alternative to hysterectomy in select patients. As interventional radiologists gain more experience in the treatment of fibroids, new interest is being directed toward arterial communications between the uterine arteries and ovarian arteries. This case report focuses on the potentially serious complication of flow reversal up the ovarian artery into the aorta during UAE.

Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization.

PURPOSE: To prospectively study and classify the anastomoses between the ovarian and uterine arteries in women undergoing uterine fibroid embolization, and to compare the presence of such with procedural failures and premature menopause. MATERIALS AND METHODS: Angiographic ovarian artery-to-uterine artery anastomoses were studied in 76 consecutive patients undergoing uterine fibroid embolization. Mean patient age was 44.7 years (range, 29-56 years). Clinical follow-up consisted of a standard questionnaire. Procedural failure and complications were compared with the presence of various types of ovarian artery-to-uterine artery connections. RESULTS: Three types of anastomoses were identified. In type I (33 [21.7%] of 152 arteries), flow from the ovarian artery to the uterus was through anastomoses with the main uterine artery. In type II (six arteries [3.9%]), the ovarian artery supplied the fibroids directly. In type III (10 arteries [6.6%]), the major blood supply to the ovary was from the uterine artery. Seven patients (9%) were considered to have clinical failure, with three of the six women with type II anastomoses being in this group. Three of the five women who experienced menopause after fibroid embolization had bilateral ovarian artery-to-uterine artery anastomoses that were classified as high risk. CONCLUSION: Delineation of ovarian artery-to-uterine artery anastomosis is of practical relevance in avoiding nontarget ovarian embolization, in identification of those who would be at risk of uterine artery embolization or ovarian failure, and in those in whom the ovarian artery can be embolized safely.