Faculty Bibliography

Background. Since its introduction in 1996, uterine fibroid embolization (UFE) has become standard medical practice in the management of symptomatic uterine fibroids. An extremely rare complication, pyomyoma, has been reported only 5 times previously in the literature following UFE. Case. A 37-year-old woman underwent UFE for symptomatic leiomyomas of the uterus. Signs and symptoms of uterine infection ensued, beginning at 6 days following the procedure. Recurrent fevers and increasing leukocytosis despite the intravenous administration of appropriate antibiotics eventually necessitated surgical intervention on postprocedure day #18. Conclusion. An extremely rare complication of UFE is herein presented, pyomyoma, with a review of other reported cases. Commonalities are sought among these few reported cases with the hope of increasing diagnostic acumen in the detection of this disease.

Despite progress in noninvasive imaging with computed tomography and magnetic resonance imaging, conventional angiography still contributes to the diagnostic workup of oncologic and other diseases. Arteriography can reveal tumors not evident on cross-sectional imaging, in addition to defining aberrant or unexpected arterial supply to targeted lesions. This additional and potentially unanticipated information can alter management decisions during interventional procedures.

Purpose: To identify variables predicting active extravasation and contrast-induced nephropathy (CIN) in angiography performed for acute bleeding. Material and methods: We retrospectively reviewed all conventional angiograms performed for acute bleeding (1/2013 to 6/2015), including 75 angiograms (46 gastrointestinal; 29 other sources of intra-abdominal bleeding cases) in 70 patients (26 women; 44 men) with a mean age of 59 (range 21-92) years. We recorded demographic information, comorbidities, vital signs immediately preceding angiography, post-procedure complications, and change in hematocrit (DELTAHct) and fluids and blood products administered over the 24 hours prior to angiography. Results: Of 75 exams, 20 (27%) showed contrast extravasation. DELTAHct was the only independent predictor of contrast extravasation (p=0.017). Patients with active extravasation had larger DELTAHct than those without extravasation (-17% vs. -1%; p=0.01). CIN occurred after 10 of 66 angiograms (15%), with GFR being the only independent predictor (p=0.03); 8% of patients with normal renal function (GFR>60) developed CIN; 29% of patients with mild-moderate impairment (GFR 30-60) developed CIN; and 67% of patients with severe renal impairment (GFR<30) developed CIN after angiography. Conclusion: Greater decrease in hematocrit over the 24 hours prior to angiography for intra-abdominal bleeding is an independent predictor of active extravasation, whereas pre-existing renal impairment is the independent predictor of CIN. The potential benefit of diagnosing active extravasation in patients with large hematocrit declines can be weighed against the risk of renal impairment

Purpose: Spontaneous bacterial peritonitis (SBP) is diagnosed by analysis of ascites obtained by image-guided paracentesis. We aimed to determine accurate predictors and whether SBP can occur in low-volume ascites. Material and methods: From 7/16 to 10/16, 243 paracenteses were performed in 99 patients (42 women, 57 men; mean age 63 years). Clinical symptoms, lab values, depth of the deepest pocket on ultrasound, total volume of ascites drained, cultures, neutrophil count (NC = total fluid nucleated cells x %neutrophils), and complications were recorded. Multiple logistic regressions were performed with age, gender, indication, cirrhosis, cancer, abdominal pain, fever, confusion, prior SBP, depth of largest fluid pocket documented on ultrasound, total volume of ascites drained, and most recent labs (INR, platelets, WBC, and sodium) as independent variables. Results: Of 243 cases, 11 cases were diagnosed with SBP by NC>250, 2 of which had positive cultures (Citrobacter and Enterococcus). One case with NC 123 had a positive culture with Citrobacter and considered SBP. Multiple logistic regression for diagnosis of SBP was significant (p<0.0001); abdominal pain (p=0.006) and depth of the deepest pocket (p=0.01) were the only significant independent predictors. All cases of SBP had deepest pockets >5cm; SBP cases had pockets of mean 7.7 cm, compared with 6.3 cm for negative cases (p=0.03). There were 2 major hemorrhagic complications (0.8%); regression demonstrated no predictors of complications. Conclusion: Large ascites pocket and abdominal pain predicted SBP; SBP was never diagnosed in patients with pockets <5cm. Given the potential for hemorrhagic complications (~1%), appropriate patient selection for paracentesis may include excluding patients with small ascites pockets on ultrasound

Purpose: Fibroid non-enhancement is considered to be a relative contraindication to uterine artery embolization (UAE) for symptomatic fibroids because embolization is not thought to have an impact on necrotic fibroids. The purpose was to assess the impact of UAE on necrotic fibroids and determine imaging predictors of fibroid shrinkage. Material and methods: A retrospective review of all women who underwent UAE for symptomatic fibroids 5/09-7/14 and underwent a follow-up MRI 4-6 months after UAE was included. There were 59 fibroids (5 non-enhancing, 54 enhancing) among 18 women with a mean age of 46 (range 40-53) years. All fibroids were assessed for size, position (submucosal, subserosal, and intramural), enhancement on subtraction images, and apparent diffusion constant (ADC). Results: Enhancing fibroids had an average decrease in diameter of 21% (SE 3%); necrotic fibroids had an average decrease in diameter of 12% (SE 1%) (p=0.2). Multiple linear regression with percent change in fibroid diameter as the dependent variable and patient age, pre-UAE fibroid diameter, enhancement, and ADC as independent variables were not significant (p=0.18), though ADC (p=0.04) and diameter (p=0.03) as independent predictors were significant. Smaller diameter and higher ADC were associated with greater decreases in size. Conclusion: Non-enhancing fibroids did reduce in size after UAE, perhaps to a lesser extent than enhancing fibroids. Pre-UAE size and ADC were predictors of diameter reduction but not enhancement

Purpose: Delineate sources of increased radiation during, cost of, and difficult retrieval after IVC filter (IVCF) placement. Material and methods: All 299 IVCFs (8/2013-12/2014) were identified by PACS search, 252 placed in a fluoroscopy suite (FS) and 47 in the operating room (OR), and reviewed for radiation exposure, fluoroscopy time, filter type, and angulation. Filter removals were assessed for the number of retrieval devices needed and fluoroscopy time. Results: Multiple linear regressions revealed that jugular versus femoral access and filter type had no impact on radiation exposure. However, filters placed in the OR entailed more radiation than in the FS (156.3 vs 71.4 mGy; p=0.001), longer fluoroscopy time (6.1 vs 2.8 min; p<0.0001), and resulted in greater filter angulation (4.8 vs 2.6degree; p<0.0001). Filter angulation was primarily dependent on the filter type (p=0.02), with the Venatech and Denali filters associated with decreased angulation (2.2 and 2.4degree, respectively), and the Option, Celect, and Meridian filters associated with greater angulation (4.2, 4.6, 4.7degree, respectively). There was a 32% retrieval rate. Filter angulation, but not filter type or filtration duration, independently predicted cases requiring more >1 retrieval device (p=0.0008) and >30 min fluoroscopy time (p=0.02). Cost savings for IVCF placement in the FS versus OR were estimated at $444.50/case. Conclusion: Increased radiation and cost were associated with placement in the OR, compared to the FS. Filter angulation was the primary determinant of difficulty in removing filters, while angulation was determined by filter type. Performing IVCF placement in the FS using specific filters may reduce radiation and cost, while enabling subsequent ease of retrieval

Purpose: Obesity is associated with increased risk of hepatocellular carcinoma (HCC), with higher rates of complications and disease recurrence after liver transplantation and ablation. We studied the impact of obesity on outcomes after transarterial chemoembolization (TACE). Material and Methods: We retrospectively identified 114 TACE (58 HCC patients; 85% due to hepatitis B or C; mean age, 62 years; mean MELD score, 10; mean AFP, 805). Medical charts were assessed for body mass index (BMI), clinical, and procedural data. The 1-2-month follow-up CT or MRI was assessed using mRECIST criteria for residual/ recurrent disease or new lesions. For analysis, patients were grouped by low (<25) and high (>25) BMI. Results: Residual/recurrent disease on 1-2-month imaging was more common after TACE in patients with high BMI than in those with low BMI (63% vs. 31%; X2: 8.3; p=0.004), as were new lesions (42% vs. 19%; X2: 4.9; p=0.02). Mean BMI differed between cases with complete response (mean, 25+/-1), stable disease/partial response (mean, 29; SE, 1), or progressive disease (mean, 29+/-1) by one-way ANOVA (p=0.003). Of 58 patients, 9 had complications. Patients with complications had higher BMI than those without complications (30 vs. 27; p=0.05 by Mann-Whitney U test). Two deaths within 1 month occurred in obese patients (BMI, 33 and 34). Conclusion: High BMI is associated with more residual/recurrent disease, new lesions, and progressive disease after TACE for HCC and possibly with increased complications. Obesity may lead to a more rapidly progressive and difficult to treat HCC