Patients with pelvic congestion syndrome, which is the part of pelvic venous disorders (PeVDs), present with unexplained chronic pelvic pain greater than six months, and anatomical findings including ...pelvic venous insufficiency and pelvic varicosities. Venography is usually necessary to confirm ovarian vein reflux and should be the first step of embolization. Endovascular therapy has been validated by several large patient series with long-term follow-up and should be the first-line therapy. Embolization has been shown to be significantly more effective than surgical therapy in improving symptoms in patients who fail hormonal therapy. Briefly, the goal is to eliminate the ovarian vein reflux with direct sclerosis or embolization of enlarged pelvic varicosities. Symptom improvement is seen in 70 to 90% of the treated patients, despite technical variation. Different embolic agents can be used for this purpose. Therefore, in this review, we discuss the different types of treatment available, with focus on embolic materials.
This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and ...presents new clinically relevant recommendations.
An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.
Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable ...outcome. In as many as 12%-17% of patients,endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduo-denal ulcers after failed endoscopic hemostasis. Here,we present an overview of indications,techniques,and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment,can be performed with high technical and clinical success rates,and should be considered the salvage treatment of choice in patients at high surgical risk.
Objectives
To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer ...bleeding and to identify factors associated with early rebleeding and 30-day mortality.
Methods
Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008–2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors.
Results
The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22–0.99;
p =
.047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13–50.14;
p =
.024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01–40.52;
p =
.047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10–10.74;
p =
.006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min,
p
= .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively,
p
= .786).
Conclusions
Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding.
Key Points
•
Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue
vs.
other embolic agents.
•
The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents.
•
NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.
To assess the radiation dose and image quality of cardiac computed tomography angiography (CCTA) in an acute stroke imaging protocol using a deep learning reconstruction (DLR) method compared to a ...hybrid iterative reconstruction algorithm.
Retrospective analysis of 296 consecutive patients admitted to the emergency department for stroke suspicion. All patients underwent a stroke CT imaging protocol including a non-enhanced brain CT, a brain perfusion CT imaging if necessary, a CT angiography (CTA) of the supra-aortic vessels, a CCTA and a post-contrast brain CT. The CCTA was performed with a prospectively ECG-gated volume acquisition. Among all CT scans performed, 143 were reconstructed with an iterative reconstruction algorithm (AIDR 3D, adaptive iterative dose reduction three dimensional) and 146 with a DLR algorithm (AiCE, advanced intelligent clear-IQ engine). Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality (IQ) scored from 1 to 4 were assessed. Dose-length product (DLP), volume CT dose index (CTDIvol) and effective dose (ED) were obtained.
The radiation dose was significantly lower with AiCE than with AIDR 3D (DLP =106.4±50.0
176.1±37.1 mGy·cm, CTDIvol =6.9±3.2
11.5±2.2 mGy, and ED =1.5±0.7
2.5±0.5 mSv) (P<0.001). The median SNR and CNR were higher 9.9 (IQR, 8.1-12.3); and 12.6 (IQR, 10.5-15.5), respectively, with AiCE than with AIDR 3D 6.5 (IQR, 5.2-8.5); and 8.4 (IQR, 6.7-11.0), respectively (P<0.001). SNR and CNR were increased by 51% and 49%, respectively, with AiCE compared to AIDR 3D. The image quality was significantly better with AiCE (mean IQ score =3.4±0.7) than with AIDR 3D (mean IQ score =3±0.9) (P<0.001).
The use of a DLR algorithm for cardiac CTA in an acute stroke imaging protocol reduced the radiation dose by about 40% and improved the image quality by about 50% compared to an iterative reconstruction algorithm.
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