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Purpose: To assess current uterine fibroid embolisation (UFE) practice in European countries and determine the clinical environment for UFE in different hospitals.Material and Methods: In May 2009, an invitation for an online survey was sent by e-mail to all members of the Cardiovascular and Interventional Radiologic Society of Europe, representing a total number of 1,250 different candidate European treatment centres. The survey covered 21 questions concerning local UFE practice.Results: A total of 282 respondents completed the questionnaire. Fifteen questionnaires were excluded because they were doubles from centres that had already returned a questionnaire. The response rate was 267 of 1,250 centres (21.4%). Ninety-four respondents (33%) did not perform UFE and were excluded, and six centres were excluded because demographic data were missing. The remaining 167 respondents from different UFE centres were included in the study. Twenty-six percent of the respondents were from the United Kingdom (n = 43); 16% were from Germany (n = 27); 11% were from France (n = 18); and the remaining 47% (n = 79) were from other European countries. Most centres (48%, n = 80) had 5 to 10 years experience with UFE and performed 10 to 50 procedures annually (53% [n = 88]) of respondents). Additional demographic data, as well as specific data on referral of patients, UFE techniques used, and periprocedural and postprocedural, care will be provided.Conclusion: Although UFE as an alternative treatment for hysterectomy or myomectomy is widespread in Europe, its impact on the management of the patient with symptomatic fibroids seems, according to the overall numbers of UFE procedures, somewhat disappointing. Multiple factors might be responsible for this observation. [ABSTRACT FROM AUTHOR]

Uterine artery embolization (UAE) in patients with a large fibroid burden is controversial. Anecdotal reports describe serious complications and limited clinical results. We report the long-term clinical and magnetic resonance (MR) results in a large series of women with a dominant fibroid of >10 cm and/or an uterine volume of >700 cm(3). Seventy-one consecutive patients (mean age, 42.5 years; median, 40 years; range, 25-52 years) with a large fibroid burden were treated by UAE between August 2000 and April 2005. Volume reduction and infarction rate of dominant fibroid and uterus were assessed by comparing the baseline and latest follow-up MRIs. Patients were clinically followed at various time intervals after UAE with standardized questionnaires. There were no serious complications of UAE. During a mean follow-up of 48 months (median, 59 months; range, 6-106 months), 10 of 71 patients (14%) had a hysterectomy. Mean volume reduction of the fibroid and uterus was 44 and 43%. Mean infarction rate of the fibroid and overall fibroid infarction rate was 86 and 87%. In the vast majority of patients there was a substantial improvement of symptoms. Clinical results were similar in patients with a dominant fibroid >10 cm and in patients with large uterine volumes by diffuse fibroid disease. In conclusion, our results indicate that the risk of serious complications after UAE in patients with a large fibroid burden is not increased. Moreover, clinical long-term results are as good as in other patients who are treated with UAE. Therefore, a large fibroid burden should not be considered a contraindication for UAE. [ABSTRACT FROM AUTHOR]

Purpose: To compare the accuracy of computed tomography (CT) analyzed by individual radiology staff members and body imaging radiologists in a non-academic teaching hospital for the diagnosis of acute appendicitis. Patients and Methods: In a prospective study 199 patients with suspected acute appendicitis were examined with unenhanced CT. CT images were pre-operatively analyzed by one of the 12 members of the radiology staff. In a later stage two body imaging radiologist reassessed all CT images without knowledge of the surgical findings and without knowledge of the primary CT diagnosis. The results, independently reported, were correlated with surgical and histopathologic findings. Results: In 132 patients (66%) acute appendicitis was found at surgery, in 67 patients (34%) a normal appendix was found. The sensitivity of the primary CT analysis and of the reassessment was 76% and 88%, respectively; the specificity was 84% and 87%; the positive predictive value was 90% and 93%; the negative predictive value was 64% and 78%; and the accuracy was 78% and 87%. Conclusion: Reassessment of CT images for acute appendicitis by body imaging radiologists results in a significant improvement of sensitivity, negative predictive value and accuracy. To prevent false-negative interpretation of CT images in acute appendicitis the expertise of the attending radiologist should be considered. [ABSTRACT FROM AUTHOR]

Abstract Background The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is gaining popularity as a new treatment option. Many prospective and retrospective studies have reported on the effectiveness and safety of PV, but no large randomized controlled trial (RCT) has been published. Objective To estimate cost-effectiveness of PV compared to conservative therapy in terms of: pain reduction, quality of life, complications, secondary fractures and mortality. Materials and methods The VERTOS II study is designed as a prospective, multicenter RCT. Patients with a painful VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent are included and randomized for PV or conservative therapy. In total 200 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with standard questionnaires, addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score, quality of life and cost-effectiveness. Secondary fractures, necessary additional therapies and complications are recorded. Conclusion The VERTOS II study is the first methodologically sound RCT designed to assess the cost-effectiveness of PV compared to conservative therapy in patients with an acute osteoporotic VCF. Trial registration http://www.clinicaltrials.gov, NCT00232466

Between January 1, 2011, and December 31, 2016, we studied the incidence, management and outcome of high-risk breast lesions in a consecutive series of 376,519 screens of women who received biennial screening mammography. During the 6-year period covered by the study, the proportion of women who underwent core needle biopsy (CNB) after recall remained fairly stable, ranging from 39.2% to 48.1% (mean: 44.2%, 5,212/11,783), whereas the proportion of high-risk lesions at CNB (i.e., flat epithelial atypia, atypical ductal hyperplasia, lobular carcinoma in situ and papillary lesions) gradually increased from 3.2% (25/775) in 2011 to 9.5% (86/901) in 2016 (p < 0.001). The mean proportion of high-risk lesions at CNB that were subsequently treated with diagnostic surgical excision was 51.4% (169/329) and varied between 41.0% and 64.3% through the years, but the excision rate for high-risk lesions per 1,000 screens and per 100 recalls increased from 0.25 (2011) to 0.70 (2016; p < 0.001) and from 0.81 (2011) to 2.50 (2016; p < 0.001), respectively. The proportion of all diagnostic surgical excisions showing in situ or invasive breast cancer was 29.0% (49/169) and varied from 22.2% (8/36) in 2014 to 38.5% (5/13) in 2011. In conclusion, the proportion of high-risk lesions at CNB tripled in a 6-year period, with a concomitant increased excision rate for these lesions. As the proportion of surgical excisions showing in situ or invasive breast cancer did not increase, a rising number of screened women underwent invasive surgical excision with benign outcome., (© 2019 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background: Little is known about the effect of a splenic rupture on the quality of life (QOL) of patients, although the spleen is one of the most frequently injured organs in blunt abdominal trauma. It is essential to obtain more knowledge about QOL after traumatic spleen injury so that this can be taken into account when choosing treatment., Objective: The primary objective of the SPLENic Injury and Quality of life (SPLENIQ) study is to determine QOL after treatment for traumatic spleen injury. The secondary objective is to investigate clinical and imaging outcome in relation to QOL., Methods: A combination of a retrospective single-center and a prospective multicenter observational cohort study will be conducted. Patients in the retrospective study have had a splenic injury after blunt abdominal trauma and were admitted for treatment to the ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis) in Tilburg between January 2005 and February 2017. Concerning the prospective cohort study, patients with splenic injury admitted to 1 of the 10 participating hospitals between March 2017 and December 2018 will be asked to participate. The follow-up period will be 1 year regarding QOL, clinical symptoms, and imaging. Patients in the retrospective study will complete 2 questionnaires: World Health Organization QOL assessment instrument-Bref (WHOQOL-Bref) and 12-Item Short-Form Health Survey (SF-12). Patients in the prospective study will complete 5 questionnaires at 1 week, 1 month, 3 months, 6 months, and 12 months after treatment: WHOQOL-Bref, SF-12, Euroqol 5-Dimensional 5-Level (EQ-5D-5L) questionnaire, Institute for Medical Technology Assessment (iMTA) Productivity Cost Questionnaire (iPCQ), and iMTA Medical Consumption Questionnaire (iMCQ). In both the retrospective and prospective study, patients treated with splenic artery embolization will undergo magnetic resonance imaging (MRI). The retrospective group will undergo MRI once, and the prospective group will undergo MRI 1 month and 1 year after treatment. Treatment of splenic injury depends on the severity of the splenic injury, the hemodynamic condition of the patient, and the hospital's or doctor's preference. This study is observational in nature without randomization. Concerning the retrospective data, multivariate analysis of covariance will be done. With regard to the prospective data, mixed linear modeling will be performed., Results: This project was funded in April 2015 by ZonMw. The results of the retrospective study will be expected in March 2019. With regard to the prospective study, inclusion of patients was completed in December 2018 and data collection will be completed in December 2019. The first results will be expected in 2019., Conclusions: To our knowledge, this is the first study that examines QOL in patients with a traumatic spleen injury. The SPLENIQ study responds to the shortage of information about QOL after treatment for traumatic spleen injury and may result in the development of a patient-oriented protocol., Trial Registration: ClinicalTrials.gov NCT03099798; https://clinicaltrials.gov/ct2/show/NCT03099798 (Archived by WebCite at http://www.webcitation.org/714ZKV6A0)., International Registered Report Identifier (irrid): DERR1-10.2196/12391., (©Claudia PAM Raaijmakers, Paul NM Lohle, Paul Lodder, Jolanda de Vries. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 26.04.2019.)

Background: Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking., Objective: With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis., Methods: This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)-confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE., Results: Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started., Conclusions: This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients' wellbeing and quality of life., Trial Registration: Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)., (©Annefleur Machteld de Bruijn, Paul NM Lohle, Judith AF Huirne, Jolanda de Vries, Moniek Twisk, QUESTA-Trial Group, Wouter JK Hehenkamp. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.03.2018.)

Background: To determine the proportion of "true" interval cancers and tumor characteristics of interval breast cancers prior to, during and after the transition from screen-film mammography screening (SFM) to full-field digital mammography screening (FFDM)., Methods: We included all women with interval cancers detected between January 2006 and January 2014. Breast imaging reports, biopsy results and breast surgery reports of all women recalled at screening mammography and of all women with interval breast cancers were collected. Two experienced screening radiologists reviewed the diagnostic mammograms, on which the interval cancers were diagnosed, as well as the prior screening mammograms and determined whether or not the interval cancer had been missed on the most recent screening mammogram. If not missed, the cancer was considered an occult ("true") interval cancer., Results: A total of 442 interval cancers had been diagnosed, of which 144 at SFM with a prior SFM (SFM-SFM), 159 at FFDM with a prior SFM (FFDM-SFM) and 139 at FFDM with a prior FFDM (FFDM-FFDM). The transition from SFM to FFDM screening resulted in the diagnosis of more occult ("true") interval cancers at FFDM-SFM than at SFM-SFM (65.4% (104/159) versus 49.3% (71/144), P < 0.01), but this increase was no longer statistically significant in women who had been screened digitally for the second time (57.6% (80/139) at FFDM-FFDM versus 49.3% (71/144) at SFM-SFM). Tumor characteristics were comparable for the three interval cancer cohorts, except of a lower porportion (75.7 and 78.0% versus 67.2% af FFDM-FFDM, P < 0.05) of invasive ductal cancers at FFDM with prior FFDM., Conclusions: An increase in the proportion of occult interval cancers is observed during the transition from SFM to FFDM screening mammography. However, this increase seems temporary and is no longer detectable after the second round of digital screening. Tumor characteristics and type of surgery are comparable for interval cancers detected prior to, during and after the transition from SFM to FFDM screening mammography, except of a lower proportion of invasive ductal cancers after the transition.

We report a case of a 20-week pregnant woman, who underwent embolisation of a cervical fibroid to end a life-threatening massive bleeding. This is the first reported case in the literature of a super-selective uterine fibroid embolisation (UFE) in a pregnant woman, even though pregnancy is considered an absolute contraindication for UFE. This rare case demonstrates that UFE can be safely performed during pregnancy providing an excellent short- and long-term clinical outcome for both mother and child.

Purpose: This study was designed to assess midterm outcome of uterine artery embolisation (UAE) for women with therapy-resistant adenomyosis using polyzene F-coated hydrogel microspheres., Methods: Between September 2006 and January 2010, 29 consecutive women with adenomyosis (15 in combination with fibroids) were treated with UAE using polyzene F-coated hydrogel microspheres. Junction zone thickness was assessed with MRI at baseline and 3 months. Women filled out the uterine fibroid symptom and quality of life questionnaire at baseline, 3 months and after a mean clinical follow-up of 37 months (median 35, range 29-64 months)., Results: At baseline, symptom severity score of 29 women was mean 67 (median 72, range 23-100). At 3 months, this score decreased to mean 22 (median 15, range 0-66) and mean 15 (median 17, range 0-34) at final follow-up. At final follow-up of mean 37 months (median 35, range 29-64 months), 22 of 29 (76 %) patients were asymptomatic. Of these 22 women, 3 underwent a second UAE at 6, 7, and 14 months. The remaining seven patients clinically improved but still had symptoms; one underwent a hysterectomy. There was no difference in outcome between women with pure adenomyosis and women with additional fibroids. The junction zone of 4 women with additional therapy was significantly thicker compared with the remaining 25 patients., Conclusions: In women with therapy resistant adenomyosis, UAE using polyzene F-coated hydrogel microspheres resulted in 3 years preservation of the uterus in 28 of 29 (97 %) with good clinical outcome in the vast majority of patients. Initial thickness of the junction zone is related to additional therapy.

Purpose: To compare the effectiveness of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) with that of uterine artery embolisation (UAE) for treatment of uterine fibroids., Methods: Between January 2010 and January 2013, 51 women with symptomatic uterine fibroids underwent MR-HIFU. Follow-up and MR imaging were compared to 68 women treated with UAE, who fulfilled eligibility criteria for MR-HIFU - e.g., size (≤ 12 cm) and number (≤ 5) of fibroids. We compared median symptom severity (tSSS), total health-realted quality of life (HRQoL) scores, and reintervention rates. The adjusted effect on symptom relief and HRQoL improvement was calculated using multivariable linear regression. Cox regression was applied to calculate the adjusted risk of reintervention between both treatments., Results: Median tSSS improved significantly from baseline to three-month follow-up (P < 0.001) for both MR-HIFU (53.1 (IQR [40.6-68.8]) to 34.4 (IQR [21.9-46.9]) and UAE (65.3 (IQR [56.3-74.2]) to 21.9 (IQR [9.4-34.4]). In addition, significantly better HRQoL scores were observed after three months (P < 0.001). However, in multivariate analysis, UAE had a stronger effect on symptom relief and HRQoL improvement than MR-HIFU (P < 0.001). Patients treated with MR-HIFU had a 7.1 (95 % CI [2.00-25.3]; P = 0.002) times higher risk of reintervention within 12 months (18/51 vs. 3/68)., Conclusion: Both MR-HIFU and UAE result in significant symptom relief related to uterine fibroids. However, MR-HIFU is associated with a higher risk of reintervention., Key Points: • This study compared outcomes between volumetric MR-HIFU and UAE for uterine fibroids. • Both MR-HIFU and UAE result in significant symptom relief and quality of life improvement. • UAE had a stronger positive effect on the clinical outcomes. • Reintervention rate after MR-HIFU ablation was significantly higher than after UAE.

Introduction: In most breast screening programmes screen-film mammography (SFM) has been replaced by full-field digital mammography (FFDM). We compared interval cancer characteristics at SFM and FFDM screening mammography., Patients and Methods: We included all 297 screen-detected and 104 interval cancers in 60,770 SFM examinations and 427 screen-detected and 124 interval cancers in 63,182 FFDM examinations, in women screened in the period 2008-2010. Breast imaging reports, biopsy results and surgical reports of all cancers were collected. Two radiologists reviewed prior and diagnostic mammograms of all interval cancers. They determined breast density, described mammographic abnormalities and classified interval cancers as missed, showing a minimal sign abnormality or true negative., Results: The referral rate and cancer detection at SFM were 1.5% and 4.9‰ respectively, compared to 3.0% (p<0.001) and 6.6‰ (p<0.001) at FFDM. Screening sensitivity was 74.1% at SFM (297/401, 95% confidence interval (CI)=69.8-78.4%) and 77.5% at FFDM (427/551, 95% CI=74.0-81.0%). Significantly more interval cancers were true negative at prior FFDM than at prior SFM screening mammography (65.3% (81/124) versus 47.1% (49/104), p=0.02). For interval cancers following SFM or FFDM screening mammography, no significant differences were observed in breast density or mammographic abnormalities at the prior screen, tumour size, lymph node status, receptor status, Nottingham tumour grade or surgical treatment (mastectomy versus breast conserving therapy)., Conclusion: FFDM resulted in a significantly higher cancer detection rate, but sensitivity was similar for SFM and FFDM. Interval cancers are more likely to be true negative at prior FFDM than at prior SFM screening mammography, whereas their tumour characteristics and type of surgical treatment are comparable., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Little is known about the natural course of pain from vertebral compression fractures (VCF). In this study we evaluated the pain course in conservatively treated patients with back pain and a VCF on the spine radiograph., Materials and Methods: Between May 2007 and November 2008, 169 patients with back pain referred by the general practitioner for spine radiographs and with a VCF were requested to participate in this follow-up study. Base line questionnaires about visual analogue scale (VAS) score, type of treatment and use of osteoporosis medication were filled in by 82 patients. Questionnaires were repeated at 6 weeks, and at 3, 6 and 12 months. Significant pain relief was defined as a decrease in VAS score of 50% or more from baseline., Results: At baseline, mean VAS score in 82 patients was 6.9 (SD 2.0). Significant pain relief at 12 months was reported by 44 patients (54%) while in 38 patients (46%) pain relief was insufficient. No predictors for pain relief could be identified. Patients with insufficient pain relief at 12 months used significantly more analgesics and in these patients physiotherapy did better than other types of therapy., Conclusion: More than half of conservatively treated patients with back pain and VCF had sufficient pain relief at 12 months with most pain decrease in the first 3 months. However, a substantial proportion of patients still reported disabling pain. There were no predictors for the development of chronic pain. Patients with continuing pain ≥3 months after diagnosis of VCF may be candidates for vertebroplasty.

Objective: To assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) using a volumetric ablation technique for treating uterine fibroids., Methods: Forty-six premenopausal women with 58 symptomatic uterine fibroids were prospectively included for MR-HIFU. After treatment, CE-MRI allowed measurement of the non-perfused volume (NPV) ratio, defined as the non-enhancing part of the fibroid divided by fibroid volume. Clinical symptoms and fibroid size on T2W-MRI were quantified at 3 and 6 months' follow-up. The primary endpoint was a clinically relevant improvement in the transformed Symptom Severity Score (tSSS) of the Uterine Fibroid Symptom and Quality of Life questionnaire, defined as a 10-point reduction., Results: Volumetric ablation resulted in a mean NPV ratio of 0.40 ± 0.22, with a mean NPV of 141 ± 135 cm(3). Mean fibroid volume was 353 ± 269 cm(3) at baseline, which decreased to 271 ± 225 cm(3) at 6 months (P < 0.001), corresponding to a mean volume reduction of 29 % ± 20 %. Clinical follow-up showed that 54 % (25/46) of the patients reported a more than 10-point reduction in the tSSS. Mean tSSS improved from 50.9 ± 18.4 at baseline to 34.7 ± 20.2 after 6 months (P < 0.001)., Conclusion: Volumetric MR-HIFU is effective for patients with symptomatic uterine fibroids. At 6 months, significant symptom improvement was observed in 54 % of patients., Key Points: • Volumetric MR-guided high-intensity focused ultrasound is a novel ablation technique for leiomyomatosis. • We prospectively evaluated the outcome of volumetric MR-HIFU ablation for symptomatic fibroids. • This study showed that volumetric MR-HIFU results in an effective treatment. • A randomised controlled trial would set this technique in an appropriate context.

Background: The purpose of this study is to evaluate 2 patients who underwent endovascular repair directly after acute life-threatening vascular injury complicating lumbar disc surgery, and to update an overview of the literature from 2002 to gain insights into characteristics, diagnosis, treatment, and outcomes of this rare, life-threatening complication., Methods: PubMed was searched for English language studies on vascular injury (lacerations, arteriovenous fistulas, and pseudoaneurysms) complicating lumbar disc surgery by a posterior approach published from 2002. Two cases from the authors' institute were added to the review. Information on patient characteristics, diagnosis, treatment strategies, and outcomes were extracted by 2 independent reviewers., Case Reports: The first case describes a 54-year-old man who underwent lumbar disc surgery through a posterior approach (L5-S1) and became hypotensive intraoperatively. Angiography revealed an injury of the right internal iliac artery. Bleeding was successfully repaired by endovascular repair (acute balloon occlusion followed by coiling). The second case describes a 51-year-old women who suddenly became hypotensive during L4 through L5 discectomy caused by bleeding from a laceration in the right common iliac artery. Angiography confirmed the diagnosis, and the bleeding was successfully treated through endovascular repair with a covered stent., Results: A total of 56 cases from 34 articles were found in the literature since 2002, including lacerations, arteriovenous fistulas, and pseudoaneurysms. Two cases from the authors' institute were added to the review. Vascular injury was recognized intraoperatively in 36%, and within 24 hours postsurgery in 28%. The common iliac artery was most frequently affected (51%), followed by the iliac vein (23%). All lacerations were detected during surgery, whereas most arteriovenous fistulas and pseudoaneurysms were detected in the long term. Treatment consisted of open surgical repair (57%) or endovascular repair (43%). All patients survived surgery., Conclusions: Publication bias might play a role in the literature of this area because all cases survived surgery, whereas mortality rates for this condition are high. However, early recognition, diagnosis, and prompt surgical repair are essential to prevent fatal outcomes in vascular injuries complicating lumbar disc surgery. Endovascular repair is a minimally invasive, fast, and efficient treatment modality that is increasingly and preferably used because of its low morbidity and mortality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: During embolization of meningiomas, intratumoral hemorrhagic complications may occur, especially with the use of small particle sizes. We compared the rate of hemorrhagic complications in 55 patients embolized with 400-μm calibrated microspheres (Embozene) with a historical cohort of 198 patients embolized with smaller PVA particles., Materials and Methods: Between September 2009 and February 2012, fifty-five patients with 55 meningiomas were embolized with 400-μm calibrated microspheres. Indications for embolization were preoperative in 47 and before radiosurgery in 2 patients; and in 6 patients, embolization was offered as sole therapy. There were 35 women and 20 men with a mean age of 60.3 years. Mean meningioma diameter was 53 mm (range, 23-97 mm). Hemorrhagic complications were recorded., Results: There were no hemorrhagic complications in the 55 embolized patients (0%; 95% CI, 0.0%-7.8%). The difference in complication rates between 400-μm calibrated microspheres in this study (0 of 55, 0%) and small PVA particles (45-150 μm) in the historical cohort (9 of 108, 8.3%) was just short of significance (P=.066). The difference in complication rates between 400-μm calibrated microspheres (0 of 55, 0%) and larger PVA particles (150-250 μm) in the historical cohort (1 of 93, 1.1%) was not significant (P=.8)., Conclusions: In this series, embolization of meningiomas by using large (400-μm) calibrated microspheres did not result in any hemorrhagic complications.

Background: Restenosis after percutaneous transluminal angioplasty (PTA) of the superficial femoral artery (SFA) may occur in 45% of patients at 2 years follow-up. Paclitaxel-coated balloons have been found to reduce neointimal hyperplasia, and thus reduce restenosis. Recently, the Legflow(®) paclitaxel-coated balloon (Cardionovum Sp.z.o.o., Warsaw, Poland) (LPEB) has been introduced. This balloon is covered with shellac, a Food and Drug Administration (FDA) approved natural resin, to obtain an equally distributed tissue concentration of paclitaxel. The RAPID trial is designed to assess restenosis after PTA using the Legflow balloon combined with nitinol stenting versus uncoated balloons with nitinol stenting in SFA lesions >5 cm., Methods/design: A total of 176 adult patients with Rutherford class 2 to class 6 symptoms due to intermediate (5-15 cm) or long (>15 cm) atherosclerotic lesions in the SFA will be randomly allocated for treatment with LPEB with nitinol stenting or uncoated balloon angioplasty with stenting. Stenting will be performed using the Supera(®) stent in both groups (IDEV Technologies Inc., Webster, TX). The primary endpoint is the absence of binary restenosis of the treated SFA segment. Secondary outcomes are target lesion revascularization (TLR), clinical and hemodynamic outcome, amputation rate, mortality rate, adverse events, and device-specific adverse events. Follow up consists of four visits in which ankle-brachial indices (ABI), toe pressure measurements, and duplex ultrasound (DUS) will be performed. Furthermore, a peripheral artery questionnaire (PAQ) will be completed by the patients at each follow-up. In the event that DUS reveals a symptomatic >50% restenosis, or a >75% asymptomatic restenosis, additional digital subtraction angiography will be performed with any necessary re-intervention., Discussion: The RAPID trial is a multicenter randomized controlled patient blind trial that will provide evidence concerning whether the use of the Legflow paclitaxel/shellac coated balloons with nitinol stenting significantly reduces the frequency of restenosis in intermediate and long SFA lesions compared to standard PTA and stenting., Trial Registration: ISRCTN47846578.

Background and Purpose: Patients with fusiform basilar trunk aneurysms have a poor prognosis. Reconstructive endovascular therapy is possible with modern devices. We describe the clinical presentation, radiologic features, and clinical outcome of 13 patients with fusiform basilar trunk aneurysms treated with flow diverters, stents, and coils., Materials and Methods: Of the 13 patients, 7 were men and 6 were women with a mean age of 59.7 years. Clinical presentation was SAH in 3 patients, mass effect on the brain stem in 4 patients, vertebral artery dissection in 1 patient, and the aneurysm was an incidental finding in 5 patients. Mean aneurysm size was 21 mm. All except 1 were large or giant aneurysms. Nine aneurysms were partially thrombosed., Results: Stents were used in all 13 patients, in 2 patients with additional flow diverters and in 11 patients with additional coils. In 4 patients, 1 vertebral artery was subsequently occluded with coils to decrease flow into the aneurysm. Of 13 patients, 9 had a good outcome with adequate aneurysm occlusion and stable size on follow-up of 6-72 months. One of 3 patients who presented with SAH died of a rebleed 1 month later. One other patient died soon after treatment of in-stent thrombosis, and another patient became mute after treatment. In 2 of 3 patients who presented with symptoms of mass effect, there was improvement at a follow-up of 6-24 months., Conclusions: Reconstructive endovascular therapy of fusiform and dissecting basilar trunk aneurysms is feasible but carries substantial risks. The safety and effectiveness in relation to natural history has not yet been elucidated.

Background: A pseudo-aneurysm of the arteria uterina is a rare cause of hemorrhage after gynaecological surgery. Usually there is an interval of a few days to weeks between the inciting factor and the blood loss. The often late diagnosis can lead to a life-threatening hemorrhage. Correct diagnosis is necessary because a therapeutic curettage may worsen the blood loss. On ultrasound a pseudo-aneurysm can be suspected by the typical image of a anechogenicity with varying turbulent flow on doppler ultrasound. The gold standard for treatment is a arterial embolization that is minimal invasive, has a high success rate and can store the fertility., Case Description: A 32-year old woman underwent a curettage because of an incomplete miscarriage. Nine days after surgery the blood loss increased. A pseudo-aneurysm was diagnosed and treated successfully by an embolization of the right uterine artery., Conclusion: Hemorrhage is the most common complication of a curettage. Delayed blood loss after curettage can be caused by a pseudo-aneurysm. In literature there are mostly case reports of pseudo-aneurysms as a cause of a late postpartum haemorrhage after a caesarean section. Arterial embolization is the gold standard for the treatment of a pseudo-aneurysm with a high success rate and conservation of fertility. The advantage is that diagnosis and treatment can happen at once, so there is no time lost. The indication for curettage should be made correctly given the possible adverse effects.

Background and Purpose: We analyzed the natural course of conservatively treated osteoporotic vertebral compression fractures from VERTOS II, a randomized trial of vertebroplasty and conservative therapy in 202 patients with vertebral compression fractures. We assessed the proportion of patients who developed chronic back pain and possible risk factors., Materials and Methods: In VERTOS II, the VAS score was assessed at regular intervals until 1 year follow-up. We followed 95 conservatively treated patients until sufficient pain relief, defined as a VAS score ≤3. These patients were censured at the involved follow-up interval. In addition, baseline clinical and imaging data, and class of pain medication used in patients with a VAS score ≤3 at any follow-up interval were compared with those in patients with a VAS score >3 at every follow-up by using logistic regression analysis., Results: During 1 year of follow-up, 57 of 95 patients (60%) had sufficient pain relief with VAS scores ≤3. Thirty-eight patients (40%) still had pain with VAS-scores ≥4 at the last follow-up interval of 12 months, despite the use of higher class pain medication. Statistical analysis showed no risk factors., Conclusions: In the VERTOS II trial, most conservatively treated patients with acute osteoporotic compression fractures had sufficient pain relief during the first 3 months. However, after 1 year, a substantial proportion of patients still had disabling pain despite higher class pain medication used. There were no predictors for the development of chronic pain. Patients with continuing pain ≥3 months after the fracture may be candidates for vertebroplasty.

Background: The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is a new treatment option. Recent randomized controlled trials (RCT) provide conflicting results: two sham-controlled studies showed no benefit of PV while an unmasked but controlled RCT (VERTOS II) found effective pain relief at acceptable costs. The objective of this study is to compare pain relief after PV with a sham intervention in selected patients with an acute osteoporotic VCF using the same strict inclusion criteria as in VERTOS II. Secondary outcome measures are back pain related disability and quality of life., Methods: The VERTOS IV study is a prospective, multicenter RCT with pain relief as primary endpoint. Patients with a painful osteoporotic VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent, are included and randomized for PV or a sham intervention. In total 180 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with a standard Visual Analogue Scale (VAS) score for pain and pain medication. Necessary additional therapies and complications are recorded., Discussion: The VERTOS IV study is a methodologically sound RCT designed to assess pain relief after PV compared to a sham intervention in patients with an acute osteoporotic VCF selected on strict inclusion criteria., Trial Registration: This study is registered at ClinicalTrials.gov., NCT01200277.

Introduction: During percutaneous vertebroplasty (PV), perivertebral cement leakage frequently occurs. There is some concern that cement deposits may migrate towards the lungs via the veins during follow-up. We used baseline and follow-up computed tomography (CT) to assess the incidence and extend of late cement migration in a large consecutive patient cohort., Methods: VERTOS II is a prospective multicenter randomized controlled trial comparing PV with conservative therapy for osteoporotic vertebral compression fractures (OVCFs). Patients assigned to PV had baseline postprocedural CT scans of the treated vertebral bodies. After a mean follow-up of 22 months, 54 of 78 patients (69%) had follow-up CT. CT scans were analyzed and compared for perivertebral venous, discal, and soft tissue leakage., Results: Perivertebral cement leakage occurred in 64 of 80 treated vertebrae (80%; 95% CI, 70% to 87%). All patients remained asymptomatic. Perivertebral venous leakage was present in 56 vertebrae (88%), mostly in the anterior external venous plexus (46 of 56, 82%). Discal leakage occurred in 22 of 64 vertebrae (34%) and soft tissue leakage in two of 64 (4%). Mean injected cement volume in vertebrae with leakage was higher (4.5 versus 3.7 cm(3), p = 0.04). Follow-up CT scan showed unchanged perivertebral cement leakages without late cement migration., Conclusion: Perivertebral cement leaks during PV for OVCFs occurred frequently in the VERTOS II trial. Cement leakage occurred more frequently with higher injected volumes. However, all patients remained asymptomatic, and late cement migration during follow-up did not occur. Standard postprocedural CT of the treated vertebral body in PV is not necessary.

Background: Percutaneous vertebroplasty is increasingly used for treatment of pain in patients with osteoporotic vertebral compression fractures, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. We aimed to clarify whether vertebroplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures., Methods: Patients were recruited to this open-label prospective randomised trial from the radiology departments of six hospitals in the Netherlands and Belgium. Patients were aged 50 years or older, had vertebral compression fractures on spine radiograph (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Patients were randomly allocated to percutaneous vertebroplasty or conservative treatment by computer-generated randomisation codes with a block size of six. Masking was not possible for participants, physicians, and outcome assessors. The primary outcome was pain relief at 1 month and 1 year as measured by VAS score. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT00232466., Findings: Between Oct 1, 2005, and June 30, 2008, we identified 431 patients who were eligible for randomisation. 229 (53%) patients had spontaneous pain relief during assessment, and 202 patients with persistent pain were randomly allocated to treatment (101 vertebroplasty, 101 conservative treatment). Vertebroplasty resulted in greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was -5·2 (95% CI -5·88 to -4·72) after vertebroplasty and -2·7 (-3·22 to -1·98) after conservative treatment, and between baseline and 1 year was -5·7 (-6·22 to -4·98) after vertebroplasty and -3·7 (-4·35 to -3·05) after conservative treatment. The difference between groups in reduction of mean VAS score from baseline was 2·6 (95% CI 1·74-3·37, p<0·0001) at 1 month and 2·0 (1·13-2·80, p<0·0001) at 1 year. No serious complications or adverse events were reported., Interpretation: In a subgroup of patients with acute osteoporotic vertebral compression fractures and persistent pain, percutaneous vertebroplasty is effective and safe. Pain relief after vertebroplasty is immediate, is sustained for at least a year, and is significantly greater than that achieved with conservative treatment, at an acceptable cost., Funding: ZonMw; COOK Medical., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background and Purpose: PV is increasingly used as treatment for osteoporotic VCFs. However, controversy exists as to whether PV increases the risk for new VCFs during follow-up. The purpose of our research was to assess the incidence of new VCFs in patients with acute VCFs randomized to PV and conservative therapy., Materials and Methods: VERTOS II is a prospective multicenter randomized controlled trial comparing PV with conservative therapy in 202 patients. Incidence, distribution, and timing of new VCFs during follow-up were assessed from spine radiographs. In addition, further height loss during follow-up of treated VCFs was measured., Results: After a mean follow-up of 11.4 months (median, 12.0; range, 1-24 months), 18 new VCFs occurred in 15 of 91 patients after PV and 30 new VCFs in 21 of 85 patients after conservative therapy. This difference was not significant (P = .44). There was no higher fracture risk for adjacent-versus-distant vertebrae. Mean time to new VCF was 16.2 months after PV and 17.8 months after conservative treatment (logrank, P = .45). The baseline number of VCFs was the only risk factor for occurrence (OR, 1.43; 95% CI, 1.05-1.95) and number (P = .01) of new VCFs. After conservative therapy, further height loss of treated vertebrae occurred more frequently (35 of 85 versus 11 of 91 patients, P < .001) and was more severe (P < .001) than after PV., Conclusions: Incidence of new VCFs was not different after PV compared with conservative therapy after a mean of 11.4 months' follow-up. The only risk factor for new VCFs was the number of VCFs at baseline. PV contributed to preservation of stature by decreasing both the incidence and severity of further height loss in treated vertebrae.

Purpose: The authors prospectively determined the natural course of pain in patients with conservatively treated acute osteoporotic vertebral compression fractures (VCF). In addition, the type of conservative therapy that these patients received was assessed., Materials and Methods: Patients older than 50 years, referred for spine radiography for acute back pain, were asked to complete a baseline clinical questionnaire. Patients with an acute VCF were followed up at 6 and 23 months with a questionnaire that included a Visual Analog Score (VAS) and type of pain medication and other conservative treatment. Significant pain relief was defined as a decrease in VAS of 50% or more., Results: Forty-nine patients (mean age, 78 years; range, 51-95) with acute VCF were followed up for almost 2 years. Significant pain relief was noted in 22 of 35 patients (63%) at 6 months and in 25 of 36 (69%) at 23 months. In patients with persisting pain at 23 months (mean VAS 6.4), some decrease in VAS was apparent at 6 months but not in the 6-23 months interval. No predictors for significant pain relief could be identified. Patients with significant pain relief used less pain medication and had less physical therapy., Conclusions: In most patients with an acute VCF, pain decreases significantly with conservative therapy, predominantly in the first 6 months. However, almost 2 years after an acute VCF, a third of patients still had severe pain necessitating pain medication and physical therapy in the majority. No predictors for transition from acute to chronic pain could be identified., (Copyright 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The reported incidence of PCE during PV varies, depending on the sensitivity of diagnostic tests used. To assess the true incidence of PCE, we performed native chest CT during follow-up in a large proportion of patients from the VERTOS II trial., Materials and Methods: VERTOS II is a prospective multicenter randomized controlled trial comparing PV with conservative therapy in 202 patients. After a mean follow-up of 22 months (median, 21 months; range, 6-42 months), 54 of 78 patients (69%) with 80 vertebrae treated with PV underwent native chest CT to detect possible PCE. The presence, location, number, and size of PCE were recorded. In addition, the presence of pulmonary parenchymal changes adjacent to PCE was noted. Possible risk factors for PCE, such as age, sex, number of treated vertebrae, cement volume per vertebra, and presence and location of perivertebral cement leakage, were evaluated., Results: PCE was detected in 14 of 54 patients (26% 95% CI, 16%-39%). All patients were asymptomatic. Cement emboli were small and randomly distributed in peripheral small vessels. There were no reactive pulmonary changes. Cement leakage in the azygos vein was the only risk factor for the occurrence of PCE (OR, 43; 95% CI, 5-396)., Conclusions: Small and clinically silent PCE occurred in a quarter of patients treated with PV. Cement leakage into the azygos vein was the only risk factor. With time, these small cement emboli remained inert, without inflammatory pulmonary response. Standard postprocedural CT or chest radiographs are not necessary.

Background and Purpose: No consensus exists regarding pain management during PV. In this study, we evaluated the effectiveness of local infiltration anesthesia as the only pain medication., Materials and Methods: From September 2008 to March 2009, 44 consecutive patients (35 women and 9 men; mean age, 74 years) with symptomatic OVCFs were included in the study. Lidocaine was infiltrated to the skin and the periosteum of the pedicle. After PV, patients indicated pain sensation on a VAS. In addition, patients indicated the most painful moment during the procedure: lidocaine infiltration, placing the needles, or cement injection. Finally, patients were asked whether pain medication during the procedure was sufficient. After the procedure the surgeon was asked to judge the expected VAS score of the patient., Results: Mean VAS score was 5.7 (median, 6; range, 1-10). Seventeen of 44 patients (39%) indicated that lidocaine infiltration was insufficient for procedural pain reduction. The mean VAS score of these patients was 7.3 (range, 5-10). Placing the needles was specified as most painful moment in 29 patients (66%), lidocaine infiltration in 11 (25%), and cement injection in 4 (9%). Surgeons' expectations of patients' VAS scores were a mean of 3.3 (median, 3; range, 1-6)., Conclusions: For a substantial proportion of patients, local infiltration anesthesia was not sufficient for pain reduction during PV. The severity of pain experienced by the patient is usually not appreciated correctly by the surgeon.

The presence of an intrauterine device (IUD) has been traditionally considered a risk factor for postprocedural infection in patients undergoing uterine artery embolization (UAE). The authors retrospectively evaluated the occurrence of infectious complications following embolization in 20 women with IUDs. After a mean follow-up of 20.5 months, none of the patients developed an infectious complication. One patient required hysterectomy following embolization for persistent pain. Pathologic evaluation of the hysterectomy specimen demonstrated ischemia without evidence of inflammation. This experience suggests that the presence of an IUD might not be considered a contraindication for UAE., (Copyright (c) 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess complications and outcomes of uterine artery embolization (UAE) in women with pedunculated fibroids in a large single-center patient cohort., Materials and Methods: From a database with prospectively collected data from 716 women treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids. Magnetic resonance images obtained before and 3 months after UAE were used to calculate stalk diameter change and volume reduction of both the pedunculated fibroid and uterus. Two observers assessed the overall percentage infarction and infarction of pedunculated fibroid. Complications were recorded and long-term clinical follow-up (mean, 33 months; range, 10-78 months) assessed with use of a questionnaire., Results: The mean reduction in uterine and pedunculated fibroid volume was 37% and 33%, respectively. The mean reduction in stalk diameter was 0.3 cm (95% confidence interval [CI]: 0.18, 0.52 cm) or 13% from initial mean diameter. Stalk enhancement was not affected by UAE. The mean pedunculated fibroid infarction and mean overall infarction rates were 87% and 92%, respectively, for observer 1 and 88% and 92% for observer 2, with good interobserver variability. All women returned the questionnaire and no early or late complications of UAE were reported (0%; 95% CI: 0.0%-13.9%)., Conclusions: In this small series of pedunculated subserosal fibroids treated with UAE, no complications occurred. The findings suggest that the use of UAE to treat pedunculated subserosal fibroids may be safe and effective.

Objective: To assess the effects of uterine artery embolization (UAE) on psychological and sexual well-being 3 months after treatment., Design: Prospective study., Setting: Large teaching hospital in Tilburg, the Netherlands., Patient(s): 141 Premenopausal women with symptomatic uterine fibroids., Intervention(s): UAE for symptomatic fibroids., Main Outcome Measure(s): Changes in scores on a questionnaire concerning sexual well-being (ranging from 0 to 32, a higher score indicating better functioning) and a questionnaire concerning psychological well-being (SCL-90, ranging from 0 to 360, a higher score indicating more emotional and somatic concerns)., Result(s): The total score for sexual functioning showed a statistically significant increase from 20.3 to 22.7, 3 months after UAE, indicating that sexual functioning improved. Thirty-four percent and 37% of women reported an increase in sexual activity and desire. The percentage of women reporting sexual problems of lubrication, orgasm, or pain decreased 7%, 36%, and 14%, respectively. The total SCL-90 score showed a statistically significant decrease from 133 to 116, 3 months after UAE, indicating a decrease in emotional and somatic concerns., Conclusion(s): Sexual and psychological well-being improved significantly 3 months after UAE in women with symptomatic uterine fibroids. Sixty-eight percent had an increase in the total score for sexual functioning. Problems with sexual functioning were statistically significantly decreased.

Endoluminal treatment of infrapopliteal artery lesions is a matter of controversy. Bioabsorbable stents are discussed as a means to combine mechanical prevention of vessel recoil with the advantages of long-term perspectives. The possibility of not having a permanent metallic implant could permit the occurrence of positive remodeling with lumen enlargement to compensate for the development of new lesions. The present study was designed to investigate the safety of absorbable metal stents (AMSs) in the infrapopliteal arteries based on 1- and 6-month clinical follow-up and efficacy based on 6-month angiographic patency. One hundred seventeen patients with 149 lesions with chronic limb ischemia (CLI) were randomized to implantation of an AMS (60 patients, 74 lesions) or stand-alone percutaneous transluminal angioplasty (PTA; 57 patients, 75 lesions). Seven PTA-group patients "crossed over" to AMS stenting. The study population consisted of patients with symptomatic CLI (Rutherford categories 4 and 5) and de novo stenotic (>50%) or occlusive atherosclerotic disease of the infrapopliteal arteries who presented with a reference diameter of between 3.0 and 3.5 mm and a lesion length of <15 mm. The primary safety endpoint was defined as absence of major amputation and/or death within 30 days after index intervention and the primary efficacy endpoint was the 6-month angiographic patency rate as confirmed by core-lab quantitative vessel analysis. The 30-day complication rate was 5.3% (3/57) and 5.0% (3/60) in patients randomized for PTA alone and PTA followed by AMS implantation, respectively. On an intention-to-treat basis, the 6-month angiographic patency rate for lesions treated with AMS (31.8%) was significantly lower (p = 0.013) than the rate for those treated with PTA (58.0%). Although the present study indicates that the AMS technology can be safely applied, it did not demonstrate efficacy in long-term patency over standard PTA in the infrapopliteal vessels.

Background: Preoperative imaging has been demonstrated to improve diagnostic accuracy in appendicitis. This prospective study assessed the accuracy of a diagnostic pathway in acute appendicitis using ultrasonography (US) and complementary contrast-enhanced multidetector CT in a general community teaching hospital., Study Design: One hundred fifty-one patients with clinically suspected appendicitis followed the designed protocol: patients underwent operations after a primary performed positive US (graded compression technique) or after complementary CT (contrast-enhanced multidetector CT) when US was negative or inconclusive. Patients with positive CT findings underwent operations. When CT was negative for appendicitis, they were admitted for observation. Results of US and CT were correlated with surgical findings, histopathology, and followup., Results: Positive US was confirmed at operation in 71 of 79 patients and positive CT was confirmed in all 21 patients. All 39 patients with negative CT findings recovered without operations. The negative appendicitis rate was 8% and perforation rate was 9%. The sensitivity and specificity of US was 77% and 86%, respectively. The sensitivity and specificity of CT was both 100%. The sensitivity and specificity of the whole diagnostic pathway was 100% and 86%, respectively., Conclusions: A diagnostic pathway using primary graded compression US and complementary multidetector CT in a general community teaching hospital yields a high diagnostic accuracy for acute appendicitis without adverse events from delay in treatment. Although US is less accurate than CT, it can be used as a primary imaging modality, avoiding the disadvantages of CT. For those patients with negative US and CT findings, observation is safe.

Background and Purpose: During percutaneous polymethylmethacrylate (PMMA) vertebroplasty (PV), PMMA cement may migrate into the venous system and subsequently be transported to the pulmonary arteries. Frequency, outcome, and imaging findings of PMMA pulmonary embolism are poorly understood. We retrospectively assessed the frequency and outcome of PMMA embolism during PV in a large patient cohort and evaluated the relationship of the volume of injected PMMA to the occurrence of pulmonary PMMA embolism., Materials and Methods: Between 2001 and 2007, 532 osteoporotic compression fractures in 299 consecutive patients were treated with PV. PMMA embolism was defined as venous PMMA migration toward the lungs visible on biplane fluoroscopy during PV. CT was performed immediately and 1 year after PMMA migration., Results: Venous PMMA migration occurred during 11 PVs in 11 patients (2.1%, 95% confidence interval, 1.1-3.7%). CT in 8 patients demonstrated small peripheral pulmonary PMMA emboli. All 11 patients remained asymptomatic during 1-year follow-up. Repeat CT scanning after 1 year in 6 patients demonstrated unchanged pulmonary PMMA deposits without late reactive changes. Mean injected cement volume in patients with and without PMMA embolism was not different (3.6 +/- 1.06 mL versus 3.3 +/- 1.16 mL, P = .43). Similar comparison for thoracic and thoracolumbar vertebrae yielded P values of .07 and .9., Conclusion: Pulmonary PMMA embolism during PV is an infrequent complication without permanent clinical sequelae. After 1 year, no pulmonary reaction was seen on CT. No definite relationship of PMMA emboli with injected cement volume could be established.

Purpose: To evaluate long-term outcomes and factors associated with treatment failure after uterine artery embolization (UAE) in women with symptomatic uterine leiomyomas., Materials and Methods: One hundred consecutive women treated with UAE for symptomatic uterine leiomyomas participated. Clinical outcome data (ie, changes in symptoms, menstrual status, subsequent therapies) and satisfaction data were collected. Treatment failure was defined by subsequent major surgery (ie, hysterectomy or myomectomy), a second embolization, or a lack of symptom improvement at the patient's final follow-up interval. Possible predictors of failure were age, clinical baseline characteristics (ie, bleeding, pain, and bulk), and imaging results (eg, percent volume reduction of the dominant tumor). Cox proportional-hazards analysis was used to determine factors associated with failure., Results: Follow-up was available in 93 women (median follow-up, 54 months; range, 45-87 y). Continued symptom relief was observed in 72% of patients (n = 67). Among the 26 women with treatment failure (28%), 11 (42%) underwent hysterectomy, four (15%) myomectomy, and eight (31%) repeat embolization. Three (12%) reported no improvement. In women without any additional surgery (n = 70), heavy menstrual bleeding, pain, and bulk-related symptoms improved in 97%, 93%, and 92%. Ninety percent of all women (n = 93) were satisfied or very satisfied at final follow-up. Predictors of failure were a lack of improvement in bleeding (hazard ratio [HR], 9.0; 95% CI, 3.1-26.3; P < .001) or pain (HR, 7.4; 95% CI, 2.2-24.4; P < .001) at 1 year after UAE and the percent reduction in dominant tumor volume (HR, 0.97; 95% CI, 0.95-0.99; P = .007)., Conclusions: UAE in women with symptomatic leiomyomas leads to long-term symptom improvement. Predictors of failure were a lack of improvement in bleeding or pain at 1 year and the percent reduction in dominant tumor volume.

Purpose: To report the 12-month clinical and magnetic resonance (MR) imaging results of an ongoing two-center registry involving acrylamido polyvinyl alcohol (PVA) microspheres for uterine artery embolization (UAE) for leiomyomas., Materials and Methods: A total of 69 patients underwent UAE with 500-700-microm, 700-900-microm, and 900-1,200-mum acrylamido PVA microspheres (BeadBlock). Thirty-three patients underwent UAE with a limited embolization (protocol A) and 36 patients underwent UAE with stasis as the angiographic endpoint (protocol B). Primary objectives were clinical efficacy measured by a leiomyoma-specific quality of life (QOL) questionnaire and infarction rate of leiomyomas on early contrast agent-enhanced MR imaging. Secondary objectives were in-hospital complications, patient satisfaction, and frequency of clinical failure., Results: Bilateral embolization was technically successful in 68 of 69 patients. A significant decrease (P < .001) in symptom severity and increase in health-related QOL was observed at 3 and 12 months with no significant differences between embolization protocols. However, contrast agent-enhanced MR imaging showed a significantly lower rate of completely infarcted leiomyomas in protocol A compared with protocol B (P < .05). Early clinical failures in patients treated according to protocol A were caused by incomplete tumor infarction. Minor complications occurred in five of 69 patients. Patient satisfaction was similar between protocols., Conclusions: Acrylamido PVA microspheres are a clinically effective and safe embolic agent for UAE. The use of 500-700-microm spheres and a limited embolization results in an unacceptably high rate of failed tumor infarction. Superior imaging results and fewer repeat interventions can be achieved with use of 700-900-microm spheres and stasis as the angiographic endpoint.

Background: The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is gaining popularity as a new treatment option. Many prospective and retrospective studies have reported on the effectiveness and safety of PV, but no large randomized controlled trial (RCT) has been published., Objective: To estimate cost-effectiveness of PV compared to conservative therapy in terms of: pain reduction, quality of life, complications, secondary fractures and mortality., Materials and Methods: The VERTOS II study is designed as a prospective, multicenter RCT. Patients with a painful VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent are included and randomized for PV or conservative therapy. In total 200 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with standard questionnaires, addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score, quality of life and cost-effectiveness. Secondary fractures, necessary additional therapies and complications are recorded., Conclusion: The VERTOS II study is the first methodologically sound RCT designed to assess the cost-effectiveness of PV compared to conservative therapy in patients with an acute osteoporotic VCF., Trial Registration: http://www.clinicaltrials.gov, NCT00232466.

Purpose: To evaluate clinical and magnetic resonance (MR) imaging results after uterine artery embolization (UAE) in women with symptomatic adenomyosis with or without uterine leiomyomas., Materials and Methods: Thirty-eight women with symptomatic adenomyosis with or without uterine leiomyomas were treated with UAE with calibrated tris-acryl gelatin microspheres. Based on MR findings, women were categorized as having pure adenomyosis (group A; n = 15), adenomyosis dominance with fibroid tumors (group B; n = 14), or fibroid tumor dominance with adenomyosis (group C; n = 9)., Results: Heavy menstrual bleeding, pain, and bulk-related symptoms at last follow-up at a median of 16.5 months (range, 3-38 months) were compared with baseline symptoms. With follow-up MR imaging at a median of 12 months (range, 3-36 months), changes in uterine volume, leiomyoma volume, junctional zone thickness, and contrast enhancement of adenomyosis were assessed. After embolization, adenomyosis infarction could be depicted on contrast medium-enhanced MR in 44.1% of cases. Median reductions of uterine volume, fibroid tumor volume, and junctional zone thickness were 44.8%, 77.1%, and 23.9%, respectively. In group A, three patients needed additional surgery after UAE, in addition to two in group B and one in group C. In the remaining 32 patients, except for one patient in group C, all preexisting symptoms (eg, bleeding, pain, bulk-related symptoms) improved or resolved after UAE. Overall, 84.2% of women were satisfied with the results of UAE., Conclusion: In this study, midterm results (at a median of 16.5 months) showed that UAE in symptomatic adenomyosis with or without uterine leiomyomas is effective. Hysterectomy was avoided in the vast majority of patients. MR imaging showed reduction of uterine volume and junctional zone thickness.

In-stent re-stenosis is a frequent complication of endovascular stents, especially in the superficial femoral artery (SFA). Endovascular re-intervention of in- or peri-stent occlusive disease consists of recanilization through the occluded stent. In our case report, we describe the endovascular treatment of a previously placed stent in the SFA. We unintentionally passed the affected stent subintimally, in a double barrel fashion next to the first stent. The procedure was without any complications and with a successfull angiographic result. At one year follow-up the patient still has no complaints and the stent is still patent.

Purpose: To prospectively assess the short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures (VCF) treated with percutaneous vertebroplasty (PV) compared with optimal pain medication (OPM)., Methods: Randomization of patients in 2 groups: treatment by PV or OPM. After 2 weeks, patients from the OPM arm could change therapy to PV. Patients were evaluated 1 day and 2 weeks after treatment. Visual analog score (VAS) for pain and analgesic use were assessed before, and 1 day and 2 weeks after start of treatment. Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) and Roland-Morris Disability (RMD) questionnaire scores were assessed before and 2 weeks after start of treatment. Follow-up scores in patients requesting PV treatment after 2 weeks OPM treatment were compared with scores during their OPM period., Results: Eighteen patients treated with PV compared with 16 patients treated with OPM had significantly better VAS and used less analgesics 1 day after treatment. Two weeks after treatment, the mean VAS was less but not significantly different in patients treated with OPM, whereas these patients used significantly less analgesics and had better QUALEFFO and RMD scores. Scores in the PV arm were influenced by occurrence of new VCF in 2 patients. After 2 weeks OPM, 14 patients requested PV treatment. All scores, 1 day and 2 weeks after PV, were significantly better compared with scores during conservative treatment., Conclusion: Pain relief and improvement of mobility, function, and stature after PV is immediate and significantly better in the short term compared with OPM treatment.

Background and Purpose: Presence of bone marrow edema (BME) in osteoporotic vertebral compression fractures (VCF) detected by MR imaging as selection criterion for percutaneous vertebroplasty (PV) is speculative. To clarify significance of BME in VCF, we assessed pain response after PV in patients with VCF with full BME versus patients with VCF with absent BME., Methods: From a cohort of patients with painful VCF selected for PV, pain response in 14 patients with absent BME in VCF was prospectively compared with pain response in 31 patients with full BME in VCF. Pain was evaluated before PV and at 1 and 3 months after PV with visual analog scores and analgesics used. Back pain in general and at treated vertebral levels was assessed., Results: Pain decrease after PV at treated levels was observed in 10 (71%) patients with absent BME in VCF at both follow-up periods and in 29 (94%) patients with full BME 1 month after PV and 30 (97%) at 3 months after PV. Differences between the groups were significant (P = .04 at 1 month; P = .01 at 3 months). Pain response was not affected by other patient or imaging characteristics. General back pain after PV was comparable in both groups after PV (P = .08 at 1 month; P = .4 at 3 months)., Conclusion: Pain decrease after PV in patients with VCF is more frequently observed when full BME is present. Because 71% of patients with VCF with absent BME responded favorably on pain, PV should not be withheld based on absence of BME alone.

Purpose: To prospectively assess short-term, midterm, and long-term pain relief in patients with painful osteoporotic vertebral compression fractures (VCFs) treated with percutaneous vertebroplasty (PV)., Materials and Methods: Visual analog scale (VAS) scores for pain at the treated vertebral level, analgesic use, and satisfaction with outcome were assessed in 112 patients after PV of 168 VCFs. Serial follow-up was performed at 24 hours and 3, 6, and 12 months and in a small number of patients at 1-3 years. Procedure-related complications were evaluated by physical examination and computed tomography of treated levels., Results: After PV, VAS scores for pain at the individual vertebral levels treated and use of analgesic agents were significantly reduced compared with before treatment at every follow-up period. Within 24 hours after the procedure, the decreases in all scores were less compared with scores at later follow-up periods, but this was not significant. The preprocedural mean VAS score was 8.8 (range, 5-10). At follow-up, mean VAS scores ranged from 2.5 to 3.3 (range, 0-10). In the short term after PV, patients used significantly less analgesic drugs and 86% of patients were satisfied with the outcome. At midterm and long-term follow-up, patients used even less analgesic drugs and 95%-100% of patients were satisfied with the outcome of PV. Procedure-related complications with clinical consequences occurred in three patients (2.7%): one patient experienced a cardiovascular reaction, one patient had a pedicle chip fracture, and one had a rib fracture., Conclusion: PV of painful osteoporotic VCFs provides significant pain reduction in nearly all treated patients.

Background and Purpose: Little is known about the evolution of bone marrow edema (BME) in osteoporotic vertebral compression fractures (VCF) after percutaneous vertebroplasty (PV) or about its relation with relief of pain. In this study, we prospectively assessed changes in BME with MR imaging at 3, 6, and 12 months after PV and related changes in BME with pain evolution and analgesic use over time., Methods: BME percentage was assessed in 64 patients after PV of 89 VCF with serial MR imaging follow-up at 3, 6, and 12 months. Pain was assessed before PV and at every follow-up interval by visual analog scale for pain and type of analgesic used. Relation between changes in BME and pain evolution was assessed in a subgroup of 31 patients with a single treated VCF and neither new VCF at follow-up nor pain at another untreated level., Results: BME gradually decreased over time. At 1 year after PV, 29% of treated VCF still demonstrated BME. Once BME disappeared, it did not return. Pain relief was most striking the first 3 months after PV and remained constant thereafter. There was no relation between relief of pain and extent, presence, or absence of BME after PV., Conclusion: A gradual decrease of BME in osteoporotic VCF treated with PV is apparent during 12 months of MR imaging follow-up. Decrease of BME is unrelated to relief of pain.

Purpose: To evaluate the mid-term clinical results and patient satisfaction following uterine artery embolization (UAE) in women with symptomatic fibroids., Methods: Between August 1998 and December 2002, 135 patients had UAE for symptomatic uterine fibroids. All patients were asked to fill in a questionnaire. Questions were aimed at changes in bleeding, pain, and bulk-related symptoms. Symptoms after UAE were scored as disappeared, improved, unchanged or worsened. Adverse events were noted, such as vaginal dryness and discharge, menopausal complaints or fibroid expulsion. Patient satisfaction after UAE was assessed. Patient satisfaction of women embolized with polyvinyl alcohol (PVA) particles was compared with satisfaction of women embolized with calibrated microspheres., Results: The questionnaire was returned by 110 of 135 women (81%) at a median time interval of 14 months following UAE. In 10 women additional embolization or hysterectomy had been performed. Of the 110 responders, 86 (78%) were satisfied with the result of UAE. The proportion of satisfied women was higher in the group embolized with calibrated microspheres than in women embolized with PVA, although this difference was not statistically significant (p = 0.053)., Conclusion: UAE in women with symptomatic uterine fibroids leads to improvement of symptoms and patient satisfaction is good in the vast majority after a median follow-up period of 14 months.

Purpose: To assess the safety and efficacy of uterine artery embolization (UAE) using large calibrated tris-acryl gelatin microspheres., Materials and Methods: One hundred fifty-eight women with symptomatic uterine fibroids underwent UAE. Embosphere was used in 105 women and Embogold microspheres in 53 women. Major and minor complications were assessed. At 12 months, relief of symptoms and patient satisfaction were assessed and volume reductions of the uterus and dominant fibroid were calculated., Results: Median age of the subjects was 43 years (mean, 42.3 y; range, 23-53 y). Preprocedural symptoms were heavy menstrual bleeding in 89%, pain in 64%, and bulk related symptoms in 57%. At 12 months follow-up, the proportion of women with heavy menstrual bleeding, pain, and bulk-related symptoms had decreased to 9%, 8%, and 8%, respectively. Patient satisfaction was grouped as follows: very satisfied 57%, satisfied 36%, and not satisfied 7%. Mean uterine and dominant fibroid volumes before UAE were 532 cm(3) and 201 cm(3), respectively. At 12-month follow-up MR imaging, mean uterine volume decreased to 260 cm(3) and mean dominant fibroid volume to 78 cm(3). These differences were statistically significant (P < .0001). There were no procedure-related deaths. No emergency hysterectomy was needed. Permanent amenorrhea occurred in 11% of women. Transient amenorrhea occurred in 13% of women, and fibroid expulsion occurred in 10% of women. Twelve women (7.6%) had additional therapy: nine underwent additional embolization and three had hysterectomy., Conclusion: Targeted UAE using large calibrated microspheres is safe and effective in the relief of symptoms in the majority of patients. At 12 months, a marked fibroid and uterine volume reduction is obtained.