To evaluate the duration and effect of superior hypogastric nerve block (SHNB) with ropivacaine and clonidine on postinterventional pain levels and opioid requirements in patients undergoing uterine artery embolization. Postinterventional pain levels (numeric rating scale, NRS 0–10) and opioid doses were retrospectively analyzed in 53 patients undergoing transfemoral uterine artery embolization and intraprocedural superior hypogastric nerve block during 24 h. A mixture of 150 mg of ropivacaine and 150 µg of clonidine was used for the block. Postinterventional pain averaged between 1.4 and 2.0 during the first 9 h, after which a small but significant increase was observed (NRS 1.7 ± 1.6 vs. NRS 2.6 ± 2.2, p < 0.001). 70

Rationale: The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension. Presenting concerns of the patient: A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts. Diagnoses: After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made. Interventions: Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation. Outcomes: The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events. Teaching points: Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.

Background: Splenic artery embolization is an interventional treatment used to stop active bleeding in blunt splenic trauma. It is also commonly used as a prophylactic measure adjuvant to other treatments in various clinical situations to promote splenic salvage and non-operative management. The aim of this presentation is to give an overview of rationale to indications, patient selection and procedural technicalities in splenic artery embolization. Method(s): A thorough literature review was done on splenic artery embolization in blunt splenic trauma as well as non-traumatic conditions. The content was reviewed for various indications, the rationale for patient selection and use of this treatment as prophylactic or adjuvant measures to medical treatment along with its long-term effect in non-operative management. Experience of our institutional practice for this novel treatment was also added. Result(s): Blunt splenic trauma American Association for the Surgery of Trauma Grade (AAST) IV-V, is amongst most common indications for splenic artery embolization. Patient selection in AAST Grade III splenic injury is variable depending on associated findings (hemoperitoneum, active contrast blush, Pseudoaneurysm, fistula etc.), treating interventionist and trauma unit. Other indications include portal hypertension, Idiopathic thrombocytopenic purpura, Hypersplenism, thalassemia and splenic artery aneurysm with the risk of rupture. Partial versus total embolization, proximal versus distal embolization and choice of embolizing agents is variable amongst the treating interventionist depending on the indication and aim of embolization. Splenic infarction with secondary infection/abscess and non-targeted embolization are amongst the more severe, though less common complications. Conclusion(s): Splenic artery embolization is a procedure to enhance the success rate of organ salvage and non-operative management of blunt splenic trauma (AAST Grade III and above). It is also a good adjuvant measure to improve the hepatic function and variceal bleeding in portal hypertension as well as improve blood counts in various cytopenic conditions.

OBJECTIVE:The purpose of this study was to compare the efficacy of gelatin sponge with that of coils for splenic artery embolization in the treatment of blunt splenic injury.MATERIALS AND METHODS:A single-center retrospective review was performed with the records of 63 patients (45 men, 18 women; mean age, 45.5 years; range, 16-84 years) with blunt splenic injury treated at a tertiary care trauma center by splenic artery embolization with gelatin sponge (n = 30 patients) or metallic coils (n = 33 patients) between 2005 and 2014. The two groups had comparable median American Association for the Surgery of Trauma grades of IV and comparable angiographic appearances regarding active extravasation and pseudoaneurysm formation at preembolization splenic arteriography (p = 0.32). Clinical outcomes and procedure-related outcomes were evaluated.RESULTS:The success rates were similar in the two groups: splenic artery embolization failed in 6.6% (2/30) of patients in the gelatin sponge group and 12.1% (4/33) in the coil embolization group (p = 0.45; 95% CI, -30.1% to 19.2%). Major complications occurred in six patients (20.0%) in the gelatin sponge group and in six patients (18.1%) in the coil group (p = 0.85; 95% CI, -23.0% to 26.6%). Minor complications occurred in three patients (10.0%) in the gelatin sponge group and seven patients (21.2%) in the coil group (p = 0.21; 95% CI, -35.4% to 14.0%). Procedure time was significantly shorter in the gelatin sponge group (median, 32 minutes; interquartile range, 18-48 minutes) than in the coil group (median, 53 minutes; interquartile range, 30-76 minutes) (p = 0.01).CONCLUSION:Splenic artery embolization with gelatin sponge appears to be as effective and as safe as coil embolization and can be completed in a shorter time.

In their response to Connolly et al. questioning the soundness of methodology used by Agarwal et al. in lumping AV grafts and AV fistulas in their meta-analysis, Agarwal and Nadkarni made an inaccurate reference to our study by reversing our study data. They incorrectly stated that our study showed that cutting balloon group had a numerically higher patency at 3, 6, and 12months. On the contrary, our study showed a numerically lower patency after cutting balloon angioplasty at each time point compared to high pressure balloon angioplasty. Furthermore, their reasoning that the heterogeneity in their meta-analysis was acceptable does not appear to be valid because other studies have shown that the use of cutting balloon is associated with longer patency in AV grafts but not in AV fistulas. It was, therefore, incumbent upon them to split the two cohorts for analysis as lumping the two access types with different patency profiles would introduce bias and influence the outcome depending on the ratio of AV graft to AV fistulas in the mix.

Purpose: A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arterioverious (AV) fistulae for hemodialysis.Materials and Methods: Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty witha cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 rum are not available. Nine patients were excluded after angiography, with seven requiring-balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference,9 y; P = .04), but-other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo): KapIan-Meier analysis was used to compare duration of patency. Mann Whitney rank-sum t test and chi(2)/Fisher exact tests were used to compare continuous and categoric variables, respectively.Results; Technical success was achieved hi all 39 patients. At 3,. 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI]; 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%); 42.1% (95% CI, 20.25%-6.50%, and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval).Conclusions: Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve. postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

Data from observational studies of pregnant survivors of nuclear disasters and experimental studies on animals have shown that, in the first two weeks after conception, the main risk is radiation-induced pregnancy termination, which can occur at a radiation dose of 100–200 mGy. From two weeks

AIM To assess if certain triaging rules could be established to optimize the yield of mesenteric angiography. METHODS Medical records of 101 patients were retrospectively reviewed and parameters relating to age, gender, pulse rate, blood pressure, serum hemoglobin, intensive care unit (ICU) admission, and the number of packed red blood cells (PRBC) transfused in the 12 and 24 h prior to the angiography were tabulated in two groups with positive and negative angiography results. RESULTS We found no correlation between gender, pulse rate, blood pressure or serum hemoglobin and positivity of the mesenteric angiogram. But patients with positive angiogram were found to be on average 7 years older (73.2 years vs 65.9 years old) (P = 0.02). Angiogram was positive in 39.3 % (11/28) of patients admitted in ICU vs 23.2% (17/73) who were admitted elsewhere in the hospital (P = 0.03). In the 12 and 24 h prior to angiography, patients with a positive angiogram received a mean of 2.7 ± 2.3 and 3.3 ± 2.6 units of PRBC s respectively, while patients with a negative angiogram had a mean of 1.6 ± 1.9 (P = 0.02) and 2.1 ± 2.6 units (P = 0.04) received respectively in the same period. CONCLUSION Older age, ICU admission, having received at least 4 units PRBC over 12 h or 5 units over 24 h prior to angiogram are leading indicators for a positive study.

Objective: To assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis.Methods: One hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded.Results: UAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory.Conclusion: UAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.

OBJECTIVE The purpose of this meta-analysis was to determine the rates of major complications, other associated adverse events, reintervention, and clinical improvement from studies reporting complications of uterine artery embolization (UAE) for the treatment of symptomatic leiomyomas. MATERIALS AND METHODS PubMed, Medline, Embase, and Cochrane databases were searched for publications on the treatment of leiomyomas by UAE. Data pertaining to study characteristics, numbers of complications, symptomatic improvement, and reinterventions were collected by two readers. Pooled event rates were calculated using a random effects method. RESULTS Fifty-four study populations met the inclusion criteria, yielding a total of 8159 patients. There were no reported deaths. Major complications occurred at a rate of 2.9% (95% CI, 2.2-3.8%). The rate of hysterectomy for resolution of a complication from UAE was 0.7% (0.5-0.9%), and the rate of readmission was 2.7% (1.9-3.7%). Multiple other specific complications were recorded including leiomyoma tissue passage (4.7% [3.9-5.7%]), deep venous thrombosis or pulmonary embolism (0.2% [0.2-0.4%]), and permanent amenorrhea (3.9% [2.7-5.3%]). Reintervention rates including repeat UAE, myomectomy, or hysterectomy calculated per patient-year occurred at 5.3% (4.2-6.4%) with follow-up ranging from 0.25 to 5 years. Clinical symptomatic improvement ranged from 78% to 90%, with follow-up ranging from 0.25 to 2 years. CONCLUSION Symptomatic uterine leiomyoma treatment by UAE is an effective procedure with a low rate of major complications supporting its use as an alternative to hysterectomy.

Most tunneled catheters can be easily removed after the retention cuff is dissected. Occasionally, these catheters can become resistant to removal even after application of potentially hazardous forceful traction. In addition, an infected catheter may cause life-threatening septicemia. Several methods have been described for their extraction, some of which may be available only in tertiary-care facilities. The present report describes the successful extraction of five such "stuck" catheters by using a recently described technique of endoluminal dilation. The technique appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.

Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.

PURPOSE:To compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE).MATERIALS AND METHODS:Of 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure.RESULTS:On 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations.CONCLUSIONS:In comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

OBJECTIVE The purpose of this study was to describe and explain the basis for the lateral chest radiographic finding of a pseudolesion simulating a sclerotic vertebral lesion. CONCLUSION Superimposition of the scapula on the upper thoracic spine causes a vertebral pseudolesion that simulates a sclerotic lesion.

An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula. An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.

This report describes transmural penetration of the inferior vena cava (IVC) by a newly introduced IVC filter within 9 days of its placement. A computed tomographic study demonstrated filter penetration with one of the primary struts lodging in the uncinate process of the pancreas. Because of the close resemblance of this new filter to another filter that has not been associated with penetration injuries, the key differences between the two designs were examined and the determination was made that the new filter, unlike the older one, has unprotected primary struts. Only filters with an unprotected primary strut design have been associated with penetration injuries such as the one described in this case.