RESUMEN
Evaluation of the anatomic feasibility of the percutaneous transabdominal puncture of selected portal and hepatic veins in patients with cirrhosis was performed. This approach would become the framework for an image-guided robot-assisted needle drive mechanism for use in transjugular intrahepatic portosystemic shunt (TIPS) creation. Retrospective analysis of 10 CT and 14 MRI axial abdominal studies was carried out to determine whether single simultaneous transabdominal puncture of portal and hepatic veins was possible. A necessary modification of the TIPS procedure was tested in an ex vivo porcine model under fluoroscopy. Eighteen of 24 patients (75%) had intrahepatic vascular anatomy amenable to a single transabdominal puncture. Successful catheterization of portal and hepatic veins using a modified approach for TIPS was accomplished in two ex vivo porcine livers. A suitable anatomic approach for modified TIPS is present in a majority of patients with cirrhosis. Feasibility of the technique using this anatomic approach was confirmed in two ex vivo porcine models. This study serves as an initial step in a novel technical approach to TIPS using a new anatomic approach for this procedure.
Asunto(s)
Venas Hepáticas/diagnóstico por imagen , Cirrosis Hepática/diagnóstico por imagen , Vena Porta/diagnóstico por imagen , Derivación Portosistémica Intrahepática Transyugular/métodos , Animales , Estudios de Factibilidad , Venas Hepáticas/patología , Humanos , Procesamiento de Imagen Asistido por Computador , Técnicas In Vitro , Cirrosis Hepática/patología , Imagen por Resonancia Magnética , Vena Porta/patología , Porcinos , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: To evaluate the effectiveness of intraarterial lidocaine in controlling pain after uterine artery embolization (UAE). MATERIALS AND METHODS: In this double-blind prospective study, patients undergoing UAE received preservative-free 1% lidocaine or saline solution (control) in the uterine arteries before embolization. Postprocedural pain was managed with patient-controlled intravenous morphine. Attempted doses, number of doses received, total morphine dose, and maximum pain numeric rating scale (NRS) score during the postprocedural hospitalization were recorded and compared. Three-month follow-up magnetic resonance (MR) imaging and symptomatic questionnaires were collected and compared. RESULTS: Ten patients received lidocaine and eight patients received placebo. Moderate to severe vasospasm was noted in seven patients after lidocaine injection, whereas no vasospasm was noted in the placebo group (P =.004). Patients in the lidocaine group had lower NRS pain scores than those in the placebo group (P =.012), whereas there was no difference in morphine requirement between treated patients and control subjects. The study was terminated after 18 patients were treated as a result of unexpected vasospasm. CONCLUSIONS: Intraarterial 1% lidocaine is associated with moderate to severe vasospasm. Lidocaine significantly lowers subjective pain, but there is no difference in analgesic requirements. The routine use of intraarterial lidocaine is not recommended for pain control until the long-term effects of vasospasm on outcome is known.
Asunto(s)
Anestésicos Locales/uso terapéutico , Embolización Terapéutica , Leiomioma/terapia , Lidocaína/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Neoplasias Uterinas/terapia , Analgesia Controlada por el Paciente , Anestésicos Locales/administración & dosificación , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intraarteriales , Leiomioma/irrigación sanguínea , Lidocaína/administración & dosificación , Dimensión del Dolor , Estudios Prospectivos , Encuestas y Cuestionarios , Neoplasias Uterinas/irrigación sanguínea , Útero/irrigación sanguíneaRESUMEN
OBJECTIVE: To determine whether uterine artery embolization is safe and effective for treating uterine leiomyomata. METHODS: We analyzed 200 consecutive patients (61 reported previously) undergoing uterine artery embolization for the treatment of uterine leiomyomata at a single institution. After treatment, follow-up data were obtained by written questionnaire mailed to the patients at intervals of 2 weeks, 3 months, 6 months, and 12 months after treatment. Follow-up imaging was obtained at 3 months and 12 months after therapy. All complications and subsequent gynecologic interventions were recorded prospectively, obtained using the patient questionnaires and physician contact. The percentages and their 95% confidence intervals (CI) were calculated to compare the symptoms at follow-up. Proportional odds models for repeated ordinal responses were used to assess the stability of symptom improvement over time. RESULTS: The mean follow-up was 21 months (minimum 12). Heavy menstrual bleeding improved in 87% (95% CI 82%, 92%) of patients at 3 months and in 90% (95% CI 86%, 95%) at 1 year after therapy. Bulk symptoms improved in 93% of patients (95% CI 88%, 96%) at 3 months and in 91% (95% CI 86%, 95%) at 1 year after treatment. Only one major periprocedural complication occurred (pulmonary embolus), which resolved with anticoagulant therapy. Subsequent gynecologic interventions occurred in 10.5% of the patients (95% CI 7.0%, 15.0%) during the follow-up period. CONCLUSION: Uterine artery embolization is safe and controls the symptoms caused by leiomyomata in most patients.
Asunto(s)
Embolización Terapéutica , Leiomioma/terapia , Neoplasias Uterinas/terapia , Adulto , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana EdadRESUMEN
PURPOSE: To determine whether the severity of postprocedure pain associated with uterine artery embolization (UAE) for leiomyomata can be predicted and if its severity can predict outcome. MATERIALS AND METHODS: Eighty-one patients underwent UAE and had postprocedure pain managed with use of patient-controlled analgesia (PCA) in the form of an intravenous morphine pump. Baseline uterine and dominant fibroid volumes were calculated for each patient. Attempted doses, doses given, total morphine dose, and maximum numerical rating scale (NRS) score during postprocedure hospitalization were recorded. At 3 months postprocedure, repeat imaging was used to determine uterine and dominant fibroid volume reduction. Each patient also completed a questionnaire assessing change in menstrual bleeding, pelvic pain and pressure symptoms, and satisfaction with symptomatic outcome. Simple regression analysis was used to determine if baseline volumes predicted postprocedure pain and if the pain-related variables could be used to predict outcome. RESULTS: Neither baseline uterine volume nor dominant fibroid volume predicted the severity of postprocedure pain. Similarly, none of the pain-related variables predicted uterine or fibroid volume reduction, symptomatic improvement, or satisfaction with outcome. CONCLUSIONS: Postprocedural pain cannot be predicted based on baseline uterine or fibroid volume and the severity of pain experienced cannot be used to predict outcome.
Asunto(s)
Embolización Terapéutica , Leiomiomatosis/terapia , Dimensión del Dolor/métodos , Neoplasias Uterinas/terapia , Útero/irrigación sanguínea , Adulto , Analgesia Controlada por el Paciente , Analgésicos Opioides/administración & dosificación , Femenino , Humanos , Morfina/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Estudios Prospectivos , Análisis de Regresión , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
The sonographic appearance of the endometrium was evaluated in 97 infertile women, 51 from a fertility unit (FU) and 46 from an in vitro fertilization (IVF) program. Three groups of patients were identified: those with normal findings, those with an incomplete endometrial echo, and those without any endometrial echo. Findings were correlated with the type of ovulation induction protocol, the peak estradiol level, and the number of successful pregnancies. In the IVF group, 72% of the patients did not exhibit normal endometrial echoes but had adequate estradiol levels, compared with 62% of the FU patients with normal endometrial echoes but significantly lower estradiol. The data suggest that IVF patients have a nonresponsive endometrium rather than inadequate estrogen stimulation and therefore that an endometrial abnormality may be an important cause of their infertility. Ultrasound may be used as a screening method to identify such patients.