Mullerian duct anomalies: from diagnosis to intervention.

The purpose of this study was to review the embryology, classification, imaging features and treatment options of Müllerian duct anomalies. The three embryological phases will be described and the appearance of the seven classes of Müllerian duct anomalies will be illustrated using hysterosalpingography, ultrasound and MRI. This exhibit will also review the treatment options, including interventional therapy. The role of imaging is to help detect, classify and guide surgical management. At this time, MRI is the modality of choice because of its high accuracy in detecting and accurately characterising Müllerian duct anomalies. In conclusion, radiologists should be familiar with the imaging features of the seven classes of Müllerian duct anomalies, as the appropriate course of treatment relies upon the correct diagnosis and categorisation of each anomaly.

Uterine artery embolization to treat uterine fibroids.

Except for choice of embolization agent, the technique of uterine artery embolization for the treatment of fibroids is similar to that performed as emergent therapy for hemorrhage. The unique and more difficult aspects of fibroid embolization relate to patient recruitment and periprocedural care. There are few procedures in interventional radiology where timely and thoughtful pre- and postprocedure care are as important to building a practice. This is because of the intense and often prolonged clinical consequences of fibroid embolization, the attitude of many gynecologists toward interventional radiology and interventions for fibroids and especially because of the patient demographic. Patients seeking fibroid embolization tend to be highly motivated, educated women in their 20s to 40s with Internet access. The interventional radiologist unable to provide adequate answers or time to this group of patients in particular will find that they are an unforgiving lot!

Treatment of type II endoleaks with Onyx.

Endoleaks are defined as persistent perfusion of an abdominal aortic aneurysm (AAA) after endovascular stent-graft deployment. The authors describe their experience treating six endoleaks with the liquid embolic agent Onyx (ethylene-vinyl-alcohol copolymer). Complete endoleak occlusion was achieved in five of six cases. Follow-up imaging has demonstrated decreased aneurysm diameter in all patients 7-29 weeks (mean = 19.2 weeks) after treatment.

Complete inhibition of intimal hyperplasia by perivascular delivery of paclitaxel in balloon-injured rat carotid arteries.

PURPOSE: To determine whether perivascular delivery of paclitaxel prevents luminal narrowing after balloon injury by inhibiting intimal hyperplasia. MATERIALS AND METHODS: Immediately after balloon injury of the entire left common carotid artery, three slow-release formulations of paclitaxel or control formulations without drug were applied around a distal segment of the artery. The noninjured right carotid arteries were evaluated as a control. The animals were maintained for 14 and 28 days (n = 5 in each group at each time interval). Histology, immunohistochemistry, and morphometric analysis were performed. RESULTS: Injured nontreated arteries exhibited a pronounced intimal hyperplasia (0.185 +/- 0.01 mm2 at 14 days and 0.189 +/- 0.01 mm2 at 28 days) and a marked reduction in luminal area (44% at 14 days and 43% at 28 days). Medial area and the number of medial cells increased by 44% and 45%, respectively, at 14 days, and by 22% and 37%, respectively, at 28 days. Injured arteries treated with perivascular paclitaxel did not show any intimal hyperplasia, and luminal area was increased in five of six groups and was unchanged in one group. These arteries had an increased medial area but they had fewer medial cells than noninjured arteries. Injured arteries treated with control implants without paclitaxel exhibited intimal hyperplasia and luminal narrowing. CONCLUSION: Perivascular slow release of paclitaxel totally inhibits intimal hyperplasia and prevents luminal narrowing after balloon injury. Because of its efficacy, perivascular paclitaxel represents a possible approach for prevention of restenosis in humans.

A review of selective salpingography and fallopian tube catheterization.

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

Paclitaxel loaded poly(L-lactic acid) microspheres for the prevention of intraperitoneal carcinomatosis after a surgical repair and tumor cell spill.

A controlled release delivery system for paclitaxel was developed using poly(L-lactic acid) to provide local delivery to the peritoneal cavity. Microspheres were made in 1-40 and 30-120 microm size ranges. In an in vitro release study, 30-120 microm microspheres loaded with 10, 20 and 30% paclitaxel exhibited a burst phase of release for 3 days followed by an apparently zero-order phase of release. At all loadings, 20-25% of the original load of paclitaxel was released after 30 days. The effect of microsphere size on retention in the peritoneal cavity was assessed. Control 1-40 microm microspheres were injected intraperitoneally in rats. The rats received either insufflation of the peritoneal cavity using 11 mmHg CO2 or no further treatment. After sacrifice, microspheres with diameters less than 24 microm were observed in the lymphatic system after being cleared from the peritoneal cavity through fenestrations in the diaphragm. Insufflation of the peritoneal cavity had no effect on the size of microspheres that were cleared. Efficacy studies were carried out using 30-120 microm microspheres that were of sufficient size to be retained in the peritoneal cavity. In a model of a tumor cell spill after a cecotomy repair, 100 mg of 30-120 microm microspheres containing 30% paclitaxel were effective in preventing growth of tumors in the peritoneal cavity at both 2 and 6 weeks post-surgery. No gross or histologically evident tumor growth was observed on any peritoneal surfaces or in the surgical wound site. Rats receiving control microspheres all showed tumor cell implantation and growth after 2 weeks.

Post-surgical shunt hepatopulmonary syndrome in a case of non-cirrhotic portal hypertension: lack of efficacy of shunt reversal.

Hepatopulmonary syndrome, a consequence of significant liver disease and portal hypertension, is thought to be secondary to the effects of vasoactive substances, normally inactivated in the liver, on the pulmonary vasculature. We report a patient with preserved hepatic function who underwent a decompressive surgical porto-systemic shunt for non-cirrhotic portal hypertension. This patient developed hepatopulmonary syndrome with dyspnoea and oxygen desaturation 2 years post-surgical shunt. Over the next 7 years, the patient's respiratory function became increasingly impaired although hepatic function remained preserved. Because of the hypothesized role of porto-systemic shunting in the aetiology of this syndrome, the surgical shunt was successfully reversed angiographically. No improvement in dyspnoea or oxygen saturation occurred and liver transplantation was undertaken. Six months post-transplant, the patient has decreased his oxygen requirements and is free of dyspnoea. Our experience supports the causal role of porto-systemic shunting in the pathogenesis of hepatopulmonary syndrome but suggests that merely decreasing the extent of porto-systemic shunting is not beneficial. Liver transplantation remains the only reliable therapeutic modality available to these patients.

Complex uterine surgery: a cooperative role for interventional radiology with hysteroscopic surgery.

OBJECTIVE: To describe the value of concurrent interventional radiology with hysteroscopy for the management of complex intrauterine abnormalities. DESIGN: A new descriptive technique. SETTING: Tertiary care center. PATIENT(S): Three case reports. INTERVENTION(S): Interventional radiology with the placement of guidewires and/or dilatation of resistant structures may assist with hysteroscopic management of complex intrauterine abnormalities or may be a primary therapeutic option. MAIN OUTCOME MEASURE(S): Resolution of dysmenorrhea and restoration of fertility. RESULT(S): The placement of a guidewire into an occluded portion of the intrauterine cavity provides direction and safety for hysteroscopic resolution of the underlying problem. In the last case, placement of the guidewire and passing dilators over the guidewire provided complete treatment. CONCLUSION(S): The uterine cavity or a smaller segment of it may be blocked by occlusive fibrous tissue that is not amenable to standard hysteroscopic dissection. Combining radiologic imaging with hysteroscopic surgery allows visual access to instrumentation and the hidden structures or organs throughout the entire procedure. It adds complexity to the surgery but may allow restoration of function to an organ or structure that is otherwise inaccessible.

Value of echo-enhanced Doppler sonography in evaluation of transjugular intrahepatic portosystemic shunts.

OBJECTIVE: The value of echo-enhanced color and power Doppler sonography in the evaluation of transjugular intrahepatic portosystemic shunts (TIPS) was assessed and compared with that of unenhanced Doppler sonography and portal angiography. SUBJECTS AND METHODS: In a prospective randomized trial, 31 shunts in 30 patients underwent unenhanced conventional color and power Doppler sonography and portal venography including pressure measurements. The patients were allocated to either echo-enhanced conventional color Doppler sonography or echo-enhanced power Doppler sonography. For echo enhancement, a galactose-based suspension was administered IV. Shunt stenoses, if present, were quantified by percentage of stenosis and correlated with angiography, which was the gold standard. The diagnostic confidence of unenhanced and echo-enhanced Doppler sonography was assessed using a visual analog scale. RESULTS: In the diagnosis of shunt occlusion, echo-enhanced Doppler sonography yielded a sensitivity and a specificity of 100% and 100%, respectively, compared with 100% and 89%, respectively, for unenhanced Doppler sonography. Our evaluation of hemodynamically significant stenoses (portosystemic gradient > or = 15 mm Hg) found echo-enhanced Doppler sonography to be superior to unenhanced Doppler sonography (sensitivity and specificity of 82% and 83%, respectively, compared with 64% and 80%, respectively). In the detection of a shunt stenosis based on morphologic criteria only, echo-enhanced Doppler sonography yielded a sensitivity and a specificity of 78% and 100%, respectively, compared with 47% and 50%, respectively, for unenhanced Doppler sonography. Power Doppler imaging did not improve diagnostic accuracy but did increase diagnostic confidence for unenhanced Doppler sonography compared with conventional color Doppler sonography. The diagnostic confidence for sonographic evaluation of TIPS was significantly (p < .001) increased and the variability of hemodynamic measurements was markedly decreased with echo-enhanced sonography. CONCLUSION: Echo-enhanced Doppler sonography provides images of TIPS like those of angiography and allows morphologic assessment of the shunts, complementary to the essential pulsed Doppler waveform analysis that would be performed in a more guided manner. Also, echo-enhanced Doppler sonography significantly increases the sensitivity and specificity in the diagnosis of shunt dysfunction. The high diagnostic confidence and the diminished variability of spectral Doppler measurements may improve acceptance of sonographic evaluation of TIPS. Echo-enhanced Doppler sonography is safe and effective and may reduce the instances in which TIPS sonographic surveillance is nondiagnostic, in which case angiographic assessment is required.

Salpingitis isthmica nodosa: technical success and outcome of fluoroscopic transcervical fallopian tube recanalization.

PURPOSE: To evaluate the technical success and outcome of fallopian tube recanalization (FTR) in salpingitis isthmica nodosa (SIN). METHODS: SIN is a well-recognized pathological condition affecting the proximal fallopian tube and is associated with infertility and ectopic pregnancy. We reviewed the presentations, films, and case records of all patients attending for FTR for infertility from 1990 to 1994. Technical success and total, intrauterine, and ectopic pregnancy rates at follow-up were determined. RESULTS: SIN was observed in 22 of 349 (6%) patients. FTR was attempted in 34 tubes in these 22 patients. Technical success was achieved in 23 of 34 (68%) tubes affected by SIN. In 5 of the 11 failed recanalizations, failure was due to distal obstruction. At least one tube was patent on selective postprocedural salpingography in 17 of 22 (77%) patients. There were no recorded perforations or complications. At follow-up (mean 14 months), total, intrauterine, and ectopic pregnancy rates were 23%, 18%, and 4.5%, respectively. CONCLUSION: FTR in SIN is technically successful and, compared with previously reported results in unselected infertility patients, is associated with only a slightly less favorable intrauterine pregnancy rate and a comparable ectopic pregnancy rate. The findings of SIN at FTR should not discourage attempted fluoroscopic transcervical recanalization.

The talent endoluminal AAA stent-graft system. Report of the phase I USA trial, and summary of worldwide experience.

In the United States, the Phase I Feasibility Study under IDE G970065 was approved by the Food and Drug Administration on 04/11/97. The approved protocol called for implantation of the bifurcated Talent spring stent-graft system on patients who are high-risk candidates for conventional surgery because of cardio-respiratory, medical, general, or local anatomical reasons which would likely complicate the technical execution of the operation or be accompanied by a high expected mortality rate. Patient enrollment was complete with 16 cases as of September 26, 1997. This was a multicenter experience involving five different sites. This is an ongoing study and patients, of course, will continue to be followed longitudinally. Phase II will likely be approved by the FDA for initiation in January or February of 1998. Standard-risk AAA patients will be entered into the study at this time; comparison with concurrent controls will be used for comparison with conventional surgery.

Morphometric measurement of abdominal organs. Comparison of ultrasound and spiral CT.

PURPOSE: To determine interobserver variability in the morphometric measurement of abdominal organs with US and spiral CT, and to compare the results obtained with these two modalities. MATERIAL AND METHODS: US and spiral CT examinations of the abdomen were performed in 25 patients. In each patient, 13 defined distances were measured in the liver, spleen and both kidneys with US and spiral CT by two pairs of radiologists in a blinded manner. The interobserver variations of these measurements were evaluated for the US and CT examinations, and the data of both modalities were compared with one another. RESULTS: The measurement of distances in the abdomen with US and spiral CT is subject to considerable interobserver variability in both modalities. The relative interobserver variations showed marked differences, according to which distance was measured. The average interobserver variations were higher in US than in CT. A direct comparison of US and spiral CT revealed that distances obtained with CT frequently exceeded those obtained with US. CONCLUSION: Morphometric measurements of abdominal organs with US and with spiral CT showed considerable differences. The follow-up examinations should therefore be performed with the same imaging modality as used in the original examination.

Local delivery of chemotherapy: a supplement to existing cancer treatments. A case for surgical pastes and coated stents.

Local application or direct tumor injection of chemotherapeutic drugs has been proposed as a method by which local drug concentrations can be maximized in the immediate tumor environment while systemic exposure and non-target organ toxicity is minimized. Multiple opportunities are available to combine local drug delivery with widely practised, existing medical and surgical therapies. Surgical interventions, including both open and laparoscopic procedures, allow the physician to directly visualize and manipulate pathological tissues. Intraoperative placement of implantable therapeutic compounds (barriers to prevent adhesions, sustained-release antibiotics, tissue 'glues' and hemostatic agents) at or near the disease site is increasingly common in surgical practice. Less invasive therapies assisted by diagnostic imaging (fluoroscopy, ultrasound, CT and MRI scanning) have made accurate needle or catheter placement for drainage (abscesses, cysts, obstructions), injection (contrast media, pharmacological agents, embolic agents) and therapeutic purposes (endoluminal stents, venous filters) widely practised interventional medical procedures. This article describes a chemotherapeutic polymer-based paste we have developed for application at the time of surgery to reduce local recurrence of disease at tumor resection sites and a chemotherapeutic polymer-coated stent for use in the palliative management of malignant obstruction to improve the effective lifespan of the device (e.g., esophageal, biliary, prostate, and pulmonary disease). Despite the growth of local therapy in other disease states, regional cytotoxic drug therapy has not been widely deployed in the management of malignancy due to a clinical bias that local therapy will have limited utility in what is considered to be a systemic disease. In the above manner, local drug delivery could be incorporated into therapeutic protocols designed to enhance, not replace, the efficacy of existing treatment options.

Power Doppler imaging and evaluation of the resistive index in focal nodular hyperplasia of the liver.

Focal lesions of the liver represent a significant diagnostic problem for various imaging modalities. The aim of this study was to assess the value of power Doppler sonography versus conventional color Doppler imaging in the depiction of hypervascular focal nodular hyperplasia (FNH) of the liver and to investigate the resistive index (RI) in the lesions' feeding arteries. Eighteen histologically proved FNHs in 14 patients were evaluated by gray-scale ultrasound, conventional color Doppler, and power Doppler sonography. With conventional color Doppler, a feeding arterial vessel could be depicted in only 4/18 lesions and hypervascularization was detected in 6/18 lesions. Power Doppler was more sensitive in detecting feeding arteries (16/18) within hypervascular lesions (15/18). RI values in the feeding arteries (mean = 0.51) significantly differed from those in the main hepatic artery or its intraparenchymal branches (mean = 0.68) in the same patient. The mean RI-difference was 0.19, suggesting hemodynamically significant arteriovenous shunting. Power Doppler sonography significantly increases sensitivity in the diagnosis of focal nodular hyperplasia of the liver and reliably permits the distinction of these lesions from hepatocellular carcinomas.

The development of a novel intraperitoneal tumor-seeding prophylactic.

BACKGROUND: Peritoneal tumor dissemination and implantation is a complication of both open and laparoscopic oncologic surgery. This study evaluates the efficacy of paclitaxel-loaded poly(L-lactic acid) microspheres as prophylaxis against intraabdominal tumor seeding. METHODS: 2 x 10(6) 9L glioblastoma cells were introduced into the abdominal cavity of Wistar rats. Fifteen minutes later, the peritoneal cavity was washed with the experimental solutions, and 2 weeks later the presence of tumor implantation was determined. After defining the optimum dose of paclitaxel PLA microspheres in a dose-ranging study, the microsphere formulation was then compared with conventional paclitaxel in four experimental groups (n = 5) as follows: 100 mg of 30% paclitaxel-loaded microspheres; 100 mg PLA microspheres; paclitaxel 4.1 mg; and controls receiving no intraabdominal therapy. RESULTS: Although carcinomatosis developed in all control animals, none in the paclitaxel-loaded microsphere group had biopsy proven cancer. The conventional paclitaxel group (3) showed significant toxicity; only 1 animal survived and had positive histology. CONCLUSIONS: In this animal model of peritoneal carcinomatosis, the paclitaxel-loaded microsphere formulation was more effective than conventional paclitaxel in preventing tumor seeding.

Endoscopic transvaginal approach to the rabbit uterine cervix: improvement in the technique of selective tubal catheterization.

RATIONALE AND OBJECTIVES: The authors compared two methods of selective fallopian tube catheterization in female rabbits. METHODS: Technical success rates and procedure times in two groups of animals were compared. Group 1 consisted of 20 female rabbits catheterized with a fluoroscopic technique. Group 2 consisted of 55 rabbits catheterized with a combination of endoscopic and fluoroscopic guidance. RESULTS: The technique used in group 2 allowed a statistically significant reduction in the time required for cervical catheterization and the total procedural time (P < .01). There was a parallel statistically significant reduction in fluoroscopy time (P < .01). Technical success rates and adverse effects were similar for the two techniques. CONCLUSION: The combined endoscopic-fluoroscopic technique requires a shorter time than the established fluoroscopic technique and should be considered for future selective tubal catheterization experiments in rabbits.