Keith Sterling | The George Washington University (original) (raw)
Papers by Keith Sterling
Journal of Vascular and Interventional Radiology, 2019
treated. The uppermost part of the GSV treated was the SFJ in 30 patients and the knee area in 22... more treated. The uppermost part of the GSV treated was the SFJ in 30 patients and the knee area in 22 patients. The uppermost SSV area treated was the upper to mid calf (above the fascia) in 19 patients and the vein of Giacomini in the lower thigh in 3 patients. The treatment was with MOCA in all patients with the addition of foam to superficial varicosities in 52%. No complications were seen. There was no incidence of DVT. 37% of patients received a single dose of anticoagulation (Clexan 40 mg) during the procedure. At follow up Doppler ultrasound all MOCA treated veins were closed. All ulcers but one were healed at 3 months. No recurrence was seen. Conclusions: Vascular access below venous access is feasible and safe. It allows direct treatment of the ulcer bed. It appears to enhance venous ulcer healing.
CASE PRESENTATION A 32-year-old woman who is gravida 2, para 2, therapeutic abortion 0 and has a ... more CASE PRESENTATION A 32-year-old woman who is gravida 2, para 2, therapeutic abortion 0 and has a history of type 1 diabetes mellitus, uterine fibroids, and adenomyosis presents with menorrhagia and pelvic pain. She has an irregular menstrual cycle every 21 to 28 days, lasting for 5 to 7 days (3–5 days are heavy). She changes an overnight pad every hour when her cycle is heavy. She has both flooding and clot passage but does not bleed between cycles. The patient had a recent normal Pap smear and has never had an endometrial biopsy. Her surgical history is remarkable for two previous cesarean sections and a tubal ligation but no previous fibroid intervention. She would like to avoid a hysterectomy.
Journal of the American Heart Association
Background Postthrombotic syndrome is a common complication of deep vein thrombosis, with limited... more Background Postthrombotic syndrome is a common complication of deep vein thrombosis, with limited treatment options. Methods and Results ACCESS PTS (Accelerated Thrombolysis for Post‐Thrombotic Syndrome Using the Acoustic Pulse Thrombolysis Ekosonic Endovascular System) is a multicenter, single‐arm, prospective study evaluating patients with chronic deep vein thrombosis and postthrombotic syndrome (Villalta score ≥8) who received minimum 3 months of anticoagulation. Patients underwent percutaneous transluminal venoplasty and ultrasound‐accelerated thrombolysis, with data collected on clinical characteristics, postthrombotic syndrome, imaging, and quality of life to 1 year. The primary efficacy outcome was a reduction of ≥4 points in the Villalta score 30 days after procedure. The primary safety outcomes were major bleeding episodes within 72 hours and symptomatic pulmonary embolism during the index hospitalization. A total of 82 limbs (78 patients) were treated (age, 54.6±12.7 years...
JACC: Cardiovascular Interventions
Journal of Vascular and Interventional Radiology, 2016
JACC: Cardiovascular Interventions, 2015
This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and effi... more This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington). Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%. Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation. Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8;…
Radiology, 1993
A prospective study was performed to determine the frequency, type, and extent of abnormalities d... more A prospective study was performed to determine the frequency, type, and extent of abnormalities depicted with computed tomography (CT) after percutaneous biliary procedures (PBPs). Abdominal CT scans were obtained 24-72 hours after the PBP in 31 consecutive cases in 29 patients. Fifteen abnormalities were proved with CT in 14 patients (45%), as follows: subcapsular hematoma (two patients), subcapsular or perihepatic fluid collection (three patients), intrahepatic hematoma (three patients), nonspecific intrahepatic fluid collection (three patients), subcutaneous hematoma at the puncture site (one patient), free intraperitoneal air (one patient), intraperitoneal collection of contrast material (one patient), and inadvertent transxiphoid catheter tract (one patient). Only five of these patients had clinically apparent post-PBP complications that could be explained with CT findings. The 14 patients with positive CT findings required more needle passes (mean, 8.3 vs 4.6) during the PBP, ...
Techniques in Vascular and Interventional Radiology, 2002
Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be ... more Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.
Techniques in Vascular and Interventional Radiology, 2002
Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is ext... more Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFErelated complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.
CardioVascular and Interventional Radiology, 2014
Prostatic artery embolization (PAE) is becoming increasingly well recognized as an option to trea... more Prostatic artery embolization (PAE) is becoming increasingly well recognized as an option to treat men with lower urinary tract symptoms from benign prostatic hyperplasia (BPH) [1–9]. Advantages of PAE over existing transurethral techniques (microwave, laser, resection) include the lack of the following complications, which range from 5 to 15 %: urethral trauma or retrograde ejaculation, sphincter injury, nerve damage limiting sexual function, and risk of urological bleeding. This has significant clinical impact with many men avoiding surgical treatment for BPH secondary to fear of complications from existing therapies. PAE also may have a financial impact with the procedure performed on an outpatient basis, whereas the ‘‘gold standard’’ TURP procedure typically requires hospital admission. The procedure however is limited by its inherent technical challenges. Vascular anatomy supplying the prostate is varied [10] with technically challenging size and tortuosity of the target vessels. The use of smaller microcatheters (2.4-French or smaller) and those with preshaped tips are critical to overcome challenging anatomy and ensure adequate antegrade flow during embolization. Rare complications of nontarget embolization [3, 11] have been described, which is related to misrecognition of the target vessel, reflux or collateral flow to nontarget sites. Cone beam computed tomography (CBCT) in the setting of PAE has demonstrated the ability to detect potential sites of nontarget embolization prior to embolization and variant anatomy, which may allow for improved safety during embolization [12]. CBCT is considered critical during PAE, both to decrease risk, and increase operator confidence before embolization [13]. CBCT has demonstrated similar benefits with hepatic embolization [14–18], including the added benefit of predicting outcomes after embolization. Despite the increased safety in performing PAE with CBCT, there are certain pitfalls and artifacts that interventional radiologists should be aware of. In this pictorial essay, the authors set forth to illustrate the following: pseudo-rectal enhancement, retrograde opacification, penile enhancement, metallic artifacts, and venous contamination.
Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability o... more Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.
Journal of Vascular and Interventional Radiology, 2008
A postmarketing surveillance registry was conducted to monitor the safety and effectiveness of th... more A postmarketing surveillance registry was conducted to monitor the safety and effectiveness of the OptEase vena cava filter when used as a permanent filter. This study was a nonrandomized, multicenter prospective trial with all patients receiving the OptEase vena cava filter for the prevention of pulmonary embolism (PE). A total of 11 clinical sites in the United States enrolled patients. A 1-month postimplantation follow-up examination was performed to determine potential filter migration and the presence of symptomatic thrombosis of the inferior vena cava (IVC) or lower extremities. At 6-month postimplantation follow-up, patients were again assessed for the safety and stability of the filter and any clinical evidence of symptomatic thrombosis. One hundred fifty patients were enrolled in this study. Fifty-five patients (36.6%) were unable to complete all of the necessary follow-up at 6 months. At 1 month, filter migration and filter-related symptomatic deep vein thrombosis was observed in one patient each (0.9% and 0.8%, respectively). At 6 months, no new cases of filter migration or filter-related symptomatic thrombosis were observed. Filter tilting (> or = 15 degrees off the IVC axis) was observed in one patient at baseline (0.7%), four patients at 1-month follow-up (3.6%), and three patients (11.4%) at 6-month follow-up. Incidental findings on follow-up radiographs included filter fracture in two patients (1.8%) at 1 month and in one additional patient (4.3%) at 6 months. There were no clinical sequelae associated with the filter fracture. The co-primary endpoints of filter migration and symptomatic thrombus formation at 1 month had an observed frequency of 0.9% and 0.8%, respectively. These co-primary endpoints were stable and unchanged at 6 months.
Journal of Vascular and Interventional Radiology, 2014
To report early findings from a prospective United States clinical trial to evaluate the efficacy... more To report early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). From January 2012 to March 2013, 72 patients were screened and 20 patients underwent treatment. Patients were evaluated at baseline and selected intervals (1, 3, and 6 mo) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)-related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 mo). Complications were monitored and reported per Society of Interventional Radiology guidelines. Embolization was technically successful in 18 of 20 patients (90%); bilateral PAE was successful in 18 of 19 (95%). Unsuccessful embolizations were secondary to atherosclerotic occlusion of prostatic arteries. Clinical success was seen in 95% of patients (19 of 20) at 1 month, with average AUA symptom score improvements of 10.8 points at 1 month (P < .0001), 12.1 points at 3 months (P = .0003), and 9.8 points at 6 months (P = .06). QOL improved at 1 month (1.9 points; P = .0002), 3 months (1.9 points; P = .003), and 6 months (2.6 points; P = .007). Sexual function improved by 34% at 1 month (P = .11), 5% at 3 months (P = .72), and 16% at 6 months (P = .19). Prostate volume at 6 months had decreased 18% (n = 5; P = .05). No minor or major complications were reported. Early results from this clinical trial indicate that PAE offers a safe and efficacious treatment option for men with BPH.
Journal of Vascular and Interventional Radiology, 2013
To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic ar... more To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia. From January 2012 to January 2013, 15 patients (age range, 59-81 y; mean, 68 y) with moderate- or severe-grade lower urinary tract symptoms, in whom medical management had failed were enrolled in a prospective United States trial to evaluate PAE. During pelvic angiography, 15 cone-beam CT acquisitions were performed in 11 patients, and digital subtraction angiography was performed in all patients. Cone-beam CT images were reviewed to assess for sites of potential nontarget embolization that impacted therapy, a pattern of enhancement on cone-beam CT suggesting additional PAs, confirmation of prostatic parenchymal perfusion before embolization, and contralateral prostatic parenchymal enhancement. Cone-beam CT was successful in 14 of 15 acquisitions, and PAE was successful in 14 of 15 patients (92%). Cone-beam CT provided information that impacted treatment in five of 11 patients (46%) by allowing for identification of sites of potential nontarget embolization. Duplicated prostatic arterial supply and contralateral perfusion were each identified in 21% of patients (three of 11). Prostatic perfusion was confirmed before embolization in 50% of acquisitions (seven of 14). Cone-beam CT is a useful technique that can potentially mitigate the risk of nontarget embolization. During treatment, it can allow for the interventionalist to identify duplicated prostatic arterial supply or contralateral perfusion, which may be useful when evaluating a treatment failure.
Journal of Vascular and Interventional Radiology, 2006
and the UAE versus Myomectomy Study Group PURPOSE: To prospectively evaluate the safety and effec... more and the UAE versus Myomectomy Study Group PURPOSE: To prospectively evaluate the safety and effectiveness of polyvinyl alcohol (PVA) microspheres in patients undergoing uterine artery embolization (UAE) to treat uterine fibroid tumors and to compare the long-term changes in health-related quality of life (QOL) after UAE with the changes seen after myomectomy. MATERIALS AND METHODS: One hundred forty-six patients with uterine myomas were enrolled into this multicenter study, with 77 patients undergoing UAE with PVA and 69 patients undergoing myomectomy. Six-month follow-up was completed for the myomectomy, whereas 2-year follow-up was completed for the UAE group. Outcomes were assessed with the Uterine Fibroid QOL Questionnaire and based on adverse event incidence, time to return to normal activity, and changes in tumor symptom scores, QOL scores, and menorrhagia bleeding scores. For the UAE cohort, changes in total uterine volume and dominant tumor size on magnetic resonance (MR) imaging were assessed. RESULTS: In the UAE cohort, 88.3% of patients experienced a reduction of tumor-related symptoms (increase >5 points from baseline measurement) at 6 months, with 75.4% of patients in the myomectomy group experiencing similar improvement. Median QOL questionnaire scores at 6 months were found to be significantly higher in patients treated with UAE (P ؍ .041), with sustained improvement seen at 12 and 24 months. Both procedures resulted in significant reductions in 6-month menorrhagia bleeding scores, with sustained improvement in the UAE cohort at 12 and 24 months. MR imaging at 6 months revealed significant uterine and tumor volume reductions after UAE (P < .05). At least one adverse event occurred in 42% of patients in the myomectomy group, compared with 26% in the UAE group (P < .05). CONCLUSIONS: UAE performed with PVA microspheres was associated with greater sustained improvements in symptom severity and health-related QOL and with fewer complications compared with myomectomy. Six-month MR imaging data demonstrated significant reductions in uterine and tumor volumes, although the degree of tissue infarction after UAE was not assessed with contrast medium-enhanced MR imaging.
Journal of Vascular and Interventional Radiology, 1999
Journal of Vascular and Interventional Radiology, 1996
To examine the safety of pulmonary angiography with low-osmolar contrast material and modern angi... more To examine the safety of pulmonary angiography with low-osmolar contrast material and modern angiographic techniques and to analyze periprocedural complications with respect to potential predictors. A retrospective review was conducted of data from 547 consecutive patients who underwent pulmonary angiography. Minor and major complications were analyzed by using several clinical parameters. There were five major (0.9%) and 26 minor complications (4.8%). Eleven of the 26 minor complications were contrast-induced nephrotoxicity. There were no periprocedural deaths. Patients with complications had an increased incidence of coexistent pulmonary morbidities and were of a poorer physical status according to the American Society of Anesthesiology criteria. Moderate to severe pulmonary hypertension was correlated with major complications. Age, volume of contrast material used, and presence of pulmonary embolism were not correlated with complications. Pulmonary angiography is a safe procedure with an acceptable complication rate. These findings should be considered in the selection of an imaging method for the diagnosis of pulmonary embolism.
Journal of Vascular and Interventional Radiology, 2002
Journal of Vascular and Interventional Radiology, 2003
Journal of Vascular and Interventional Radiology, 2019
treated. The uppermost part of the GSV treated was the SFJ in 30 patients and the knee area in 22... more treated. The uppermost part of the GSV treated was the SFJ in 30 patients and the knee area in 22 patients. The uppermost SSV area treated was the upper to mid calf (above the fascia) in 19 patients and the vein of Giacomini in the lower thigh in 3 patients. The treatment was with MOCA in all patients with the addition of foam to superficial varicosities in 52%. No complications were seen. There was no incidence of DVT. 37% of patients received a single dose of anticoagulation (Clexan 40 mg) during the procedure. At follow up Doppler ultrasound all MOCA treated veins were closed. All ulcers but one were healed at 3 months. No recurrence was seen. Conclusions: Vascular access below venous access is feasible and safe. It allows direct treatment of the ulcer bed. It appears to enhance venous ulcer healing.
CASE PRESENTATION A 32-year-old woman who is gravida 2, para 2, therapeutic abortion 0 and has a ... more CASE PRESENTATION A 32-year-old woman who is gravida 2, para 2, therapeutic abortion 0 and has a history of type 1 diabetes mellitus, uterine fibroids, and adenomyosis presents with menorrhagia and pelvic pain. She has an irregular menstrual cycle every 21 to 28 days, lasting for 5 to 7 days (3–5 days are heavy). She changes an overnight pad every hour when her cycle is heavy. She has both flooding and clot passage but does not bleed between cycles. The patient had a recent normal Pap smear and has never had an endometrial biopsy. Her surgical history is remarkable for two previous cesarean sections and a tubal ligation but no previous fibroid intervention. She would like to avoid a hysterectomy.
Journal of the American Heart Association
Background Postthrombotic syndrome is a common complication of deep vein thrombosis, with limited... more Background Postthrombotic syndrome is a common complication of deep vein thrombosis, with limited treatment options. Methods and Results ACCESS PTS (Accelerated Thrombolysis for Post‐Thrombotic Syndrome Using the Acoustic Pulse Thrombolysis Ekosonic Endovascular System) is a multicenter, single‐arm, prospective study evaluating patients with chronic deep vein thrombosis and postthrombotic syndrome (Villalta score ≥8) who received minimum 3 months of anticoagulation. Patients underwent percutaneous transluminal venoplasty and ultrasound‐accelerated thrombolysis, with data collected on clinical characteristics, postthrombotic syndrome, imaging, and quality of life to 1 year. The primary efficacy outcome was a reduction of ≥4 points in the Villalta score 30 days after procedure. The primary safety outcomes were major bleeding episodes within 72 hours and symptomatic pulmonary embolism during the index hospitalization. A total of 82 limbs (78 patients) were treated (age, 54.6±12.7 years...
JACC: Cardiovascular Interventions
Journal of Vascular and Interventional Radiology, 2016
JACC: Cardiovascular Interventions, 2015
This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and effi... more This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington). Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%. Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation. Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) and modified Miller Index score (22.5 vs. 15.8;…
Radiology, 1993
A prospective study was performed to determine the frequency, type, and extent of abnormalities d... more A prospective study was performed to determine the frequency, type, and extent of abnormalities depicted with computed tomography (CT) after percutaneous biliary procedures (PBPs). Abdominal CT scans were obtained 24-72 hours after the PBP in 31 consecutive cases in 29 patients. Fifteen abnormalities were proved with CT in 14 patients (45%), as follows: subcapsular hematoma (two patients), subcapsular or perihepatic fluid collection (three patients), intrahepatic hematoma (three patients), nonspecific intrahepatic fluid collection (three patients), subcutaneous hematoma at the puncture site (one patient), free intraperitoneal air (one patient), intraperitoneal collection of contrast material (one patient), and inadvertent transxiphoid catheter tract (one patient). Only five of these patients had clinically apparent post-PBP complications that could be explained with CT findings. The 14 patients with positive CT findings required more needle passes (mean, 8.3 vs 4.6) during the PBP, ...
Techniques in Vascular and Interventional Radiology, 2002
Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be ... more Building a uterine fibroid embolization (UFE) practice can be a complex process. Choices must be made regarding whether to align oneself with a gynecologist or to accept direct referrals. For the interventional radiologist, the responsibilities of evaluation and patient care pose unique and time-consuming administrative and clinical challenges. Physician extenders, either nurse practitioners or physician's assistants, play key roles as clinical coordinators by guiding the patient through the medical system and making certain that she is cleared for the procedure medically and logistically. In some settings, they may also assist in many of the technical aspects of the procedure and postoperative care. Interventional radiologists must be prepared for battles with insurance companies and be willing to go through the appeals process. Business officers must also be trained to properly code for the procedures to insure optimal reimbursement. The success of building a UFE practice may also be bolstered by directly marketing to patients and by providing them with access via the Internet.
Techniques in Vascular and Interventional Radiology, 2002
Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is ext... more Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFErelated complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.
CardioVascular and Interventional Radiology, 2014
Prostatic artery embolization (PAE) is becoming increasingly well recognized as an option to trea... more Prostatic artery embolization (PAE) is becoming increasingly well recognized as an option to treat men with lower urinary tract symptoms from benign prostatic hyperplasia (BPH) [1–9]. Advantages of PAE over existing transurethral techniques (microwave, laser, resection) include the lack of the following complications, which range from 5 to 15 %: urethral trauma or retrograde ejaculation, sphincter injury, nerve damage limiting sexual function, and risk of urological bleeding. This has significant clinical impact with many men avoiding surgical treatment for BPH secondary to fear of complications from existing therapies. PAE also may have a financial impact with the procedure performed on an outpatient basis, whereas the ‘‘gold standard’’ TURP procedure typically requires hospital admission. The procedure however is limited by its inherent technical challenges. Vascular anatomy supplying the prostate is varied [10] with technically challenging size and tortuosity of the target vessels. The use of smaller microcatheters (2.4-French or smaller) and those with preshaped tips are critical to overcome challenging anatomy and ensure adequate antegrade flow during embolization. Rare complications of nontarget embolization [3, 11] have been described, which is related to misrecognition of the target vessel, reflux or collateral flow to nontarget sites. Cone beam computed tomography (CBCT) in the setting of PAE has demonstrated the ability to detect potential sites of nontarget embolization prior to embolization and variant anatomy, which may allow for improved safety during embolization [12]. CBCT is considered critical during PAE, both to decrease risk, and increase operator confidence before embolization [13]. CBCT has demonstrated similar benefits with hepatic embolization [14–18], including the added benefit of predicting outcomes after embolization. Despite the increased safety in performing PAE with CBCT, there are certain pitfalls and artifacts that interventional radiologists should be aware of. In this pictorial essay, the authors set forth to illustrate the following: pseudo-rectal enhancement, retrograde opacification, penile enhancement, metallic artifacts, and venous contamination.
Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability o... more Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.
Journal of Vascular and Interventional Radiology, 2008
A postmarketing surveillance registry was conducted to monitor the safety and effectiveness of th... more A postmarketing surveillance registry was conducted to monitor the safety and effectiveness of the OptEase vena cava filter when used as a permanent filter. This study was a nonrandomized, multicenter prospective trial with all patients receiving the OptEase vena cava filter for the prevention of pulmonary embolism (PE). A total of 11 clinical sites in the United States enrolled patients. A 1-month postimplantation follow-up examination was performed to determine potential filter migration and the presence of symptomatic thrombosis of the inferior vena cava (IVC) or lower extremities. At 6-month postimplantation follow-up, patients were again assessed for the safety and stability of the filter and any clinical evidence of symptomatic thrombosis. One hundred fifty patients were enrolled in this study. Fifty-five patients (36.6%) were unable to complete all of the necessary follow-up at 6 months. At 1 month, filter migration and filter-related symptomatic deep vein thrombosis was observed in one patient each (0.9% and 0.8%, respectively). At 6 months, no new cases of filter migration or filter-related symptomatic thrombosis were observed. Filter tilting (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 15 degrees off the IVC axis) was observed in one patient at baseline (0.7%), four patients at 1-month follow-up (3.6%), and three patients (11.4%) at 6-month follow-up. Incidental findings on follow-up radiographs included filter fracture in two patients (1.8%) at 1 month and in one additional patient (4.3%) at 6 months. There were no clinical sequelae associated with the filter fracture. The co-primary endpoints of filter migration and symptomatic thrombus formation at 1 month had an observed frequency of 0.9% and 0.8%, respectively. These co-primary endpoints were stable and unchanged at 6 months.
Journal of Vascular and Interventional Radiology, 2014
To report early findings from a prospective United States clinical trial to evaluate the efficacy... more To report early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). From January 2012 to March 2013, 72 patients were screened and 20 patients underwent treatment. Patients were evaluated at baseline and selected intervals (1, 3, and 6 mo) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)-related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 mo). Complications were monitored and reported per Society of Interventional Radiology guidelines. Embolization was technically successful in 18 of 20 patients (90%); bilateral PAE was successful in 18 of 19 (95%). Unsuccessful embolizations were secondary to atherosclerotic occlusion of prostatic arteries. Clinical success was seen in 95% of patients (19 of 20) at 1 month, with average AUA symptom score improvements of 10.8 points at 1 month (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), 12.1 points at 3 months (P = .0003), and 9.8 points at 6 months (P = .06). QOL improved at 1 month (1.9 points; P = .0002), 3 months (1.9 points; P = .003), and 6 months (2.6 points; P = .007). Sexual function improved by 34% at 1 month (P = .11), 5% at 3 months (P = .72), and 16% at 6 months (P = .19). Prostate volume at 6 months had decreased 18% (n = 5; P = .05). No minor or major complications were reported. Early results from this clinical trial indicate that PAE offers a safe and efficacious treatment option for men with BPH.
Journal of Vascular and Interventional Radiology, 2013
To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic ar... more To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia. From January 2012 to January 2013, 15 patients (age range, 59-81 y; mean, 68 y) with moderate- or severe-grade lower urinary tract symptoms, in whom medical management had failed were enrolled in a prospective United States trial to evaluate PAE. During pelvic angiography, 15 cone-beam CT acquisitions were performed in 11 patients, and digital subtraction angiography was performed in all patients. Cone-beam CT images were reviewed to assess for sites of potential nontarget embolization that impacted therapy, a pattern of enhancement on cone-beam CT suggesting additional PAs, confirmation of prostatic parenchymal perfusion before embolization, and contralateral prostatic parenchymal enhancement. Cone-beam CT was successful in 14 of 15 acquisitions, and PAE was successful in 14 of 15 patients (92%). Cone-beam CT provided information that impacted treatment in five of 11 patients (46%) by allowing for identification of sites of potential nontarget embolization. Duplicated prostatic arterial supply and contralateral perfusion were each identified in 21% of patients (three of 11). Prostatic perfusion was confirmed before embolization in 50% of acquisitions (seven of 14). Cone-beam CT is a useful technique that can potentially mitigate the risk of nontarget embolization. During treatment, it can allow for the interventionalist to identify duplicated prostatic arterial supply or contralateral perfusion, which may be useful when evaluating a treatment failure.
Journal of Vascular and Interventional Radiology, 2006
and the UAE versus Myomectomy Study Group PURPOSE: To prospectively evaluate the safety and effec... more and the UAE versus Myomectomy Study Group PURPOSE: To prospectively evaluate the safety and effectiveness of polyvinyl alcohol (PVA) microspheres in patients undergoing uterine artery embolization (UAE) to treat uterine fibroid tumors and to compare the long-term changes in health-related quality of life (QOL) after UAE with the changes seen after myomectomy. MATERIALS AND METHODS: One hundred forty-six patients with uterine myomas were enrolled into this multicenter study, with 77 patients undergoing UAE with PVA and 69 patients undergoing myomectomy. Six-month follow-up was completed for the myomectomy, whereas 2-year follow-up was completed for the UAE group. Outcomes were assessed with the Uterine Fibroid QOL Questionnaire and based on adverse event incidence, time to return to normal activity, and changes in tumor symptom scores, QOL scores, and menorrhagia bleeding scores. For the UAE cohort, changes in total uterine volume and dominant tumor size on magnetic resonance (MR) imaging were assessed. RESULTS: In the UAE cohort, 88.3% of patients experienced a reduction of tumor-related symptoms (increase >5 points from baseline measurement) at 6 months, with 75.4% of patients in the myomectomy group experiencing similar improvement. Median QOL questionnaire scores at 6 months were found to be significantly higher in patients treated with UAE (P ؍ .041), with sustained improvement seen at 12 and 24 months. Both procedures resulted in significant reductions in 6-month menorrhagia bleeding scores, with sustained improvement in the UAE cohort at 12 and 24 months. MR imaging at 6 months revealed significant uterine and tumor volume reductions after UAE (P < .05). At least one adverse event occurred in 42% of patients in the myomectomy group, compared with 26% in the UAE group (P < .05). CONCLUSIONS: UAE performed with PVA microspheres was associated with greater sustained improvements in symptom severity and health-related QOL and with fewer complications compared with myomectomy. Six-month MR imaging data demonstrated significant reductions in uterine and tumor volumes, although the degree of tissue infarction after UAE was not assessed with contrast medium-enhanced MR imaging.
Journal of Vascular and Interventional Radiology, 1999
Journal of Vascular and Interventional Radiology, 1996
To examine the safety of pulmonary angiography with low-osmolar contrast material and modern angi... more To examine the safety of pulmonary angiography with low-osmolar contrast material and modern angiographic techniques and to analyze periprocedural complications with respect to potential predictors. A retrospective review was conducted of data from 547 consecutive patients who underwent pulmonary angiography. Minor and major complications were analyzed by using several clinical parameters. There were five major (0.9%) and 26 minor complications (4.8%). Eleven of the 26 minor complications were contrast-induced nephrotoxicity. There were no periprocedural deaths. Patients with complications had an increased incidence of coexistent pulmonary morbidities and were of a poorer physical status according to the American Society of Anesthesiology criteria. Moderate to severe pulmonary hypertension was correlated with major complications. Age, volume of contrast material used, and presence of pulmonary embolism were not correlated with complications. Pulmonary angiography is a safe procedure with an acceptable complication rate. These findings should be considered in the selection of an imaging method for the diagnosis of pulmonary embolism.
Journal of Vascular and Interventional Radiology, 2002
Journal of Vascular and Interventional Radiology, 2003