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Abstract No. 260: Long term outcomes in treatment of pelvic congestion syndrome with venous embolization
S106 䡲 Wednesday
Scientific Session 䡲 JVIR
primary postpartum hemorrhage: a prospective study of 61 cases
WEDNESDAY: Scientific Sessions
D. Zhou1,2, L. Shen2, Y. Jin2, S. Bennet1, W. Wang1, G. McLennan1; 1Imaging Institute, Section of Interventional Radiology, Cleveland Clinic, Cleveland, OH; 2Department of Interventional Radiology, Nanjing Medical University Affliated Suzhou Hospital, Suzhou, China Purpose: To evaluate the efficacy and safety of selective arterial embolization (SAE) with fibrin glue compared to conventional gelatin sponges in the treatment of primary postpartum hemorrhage (PPH). Materials and Methods: From January 2006 to December 2010, 61 women with severe PPH underwent SAE (uterine artery and/or anterior division of the internal iliac artery) after failure of first-line uterotonic treatment or hysterectomy (1 patient). Fibrin glue group (FG) was used in 32 cases while gelatin sponge (GS) was used in 29 cases. Clinical success, defined as not requiring additional embolization or surgery was compared between groups. Complications and reduction in post treatment menstruation were evaluated between groups based upon patient interviews. Results: The blood loss in the FG group was 2428 ⫾ 1249 ml and 2525 ⫾ 1691 ml in the GS group. The three main causes of PPH included uterine atony (FG n⫽ 18 vs GS 14), placenta accreta/ percreta (6 vs 9), and placenta previa (4 vs 3). Six patients had a previous cesarean section in FG group and 5 in GS group. The clinical success rate of FG group was not significantly different from GS group (90.6% vs 86.2%, p⫽0.70), Seven patients were considered to be clinical failures (FG ⫽ 3, GS ⫽ 4); six required additional treatment for bleeding cessation to be achieved, which was through either hysterectomies (FG ⫽ 3, GS ⫽ 2) or with re-embolization (GS group ⫽ 1); and one patient died (GS). 31.0% (9/29) of GS patients and 12.5%(4/32) of FG patients had pain (p⫽0.036). In GS group, one woman had distal embolization to the leg. Of the 55 patients who did not undergo a hysterectomy, 49 had follow-up evaluations (FG ⫽ 25, GS ⫽ 23). Menstruation resumed in all 49 patients within 63 ⫾ 18 days in the FG group and 67 ⫾ 17 days in the GS group (F⫽0.12, p⫽0.73). Menstrual bleeding decreased in amount and frequency in 37.5% (3/28) GDS and 15.6% (5/32) FG patiens (p⫽0.20). Conclusion: SAE with fibrin glue is as effective as SAE with gelatin sponge. There is less post procedure pain with fibrin glue.
10:38 AM
Abstract No. 259
Pelvic arterial embolization in treatment of postpartum hemorrhage: clinical outcomes and predictive factor for failed embolization Y. Kim, C. Yoon, N. Seong, Y. Woo, Y. Kim; seoul national university bundang hospital, Seongnam-si, Republic of Korea Purpose: This study aims to evaluate clinical outcomes of failed pelvic arterial embolization in treatment of postpartum hemorrhage (PPH) and to determine predictive factors associated with failed procedures. Materials and Methods: Two hundred forty-six consecutive patients (age range 22-41 years; mean 33 years) who underwent pelvic arterial embolization for PPH were enrolled in this retrospective study. The medical records and imaging studies were reviewed to evaluate the incidence of failed embolization, subse-
quent intervention, complication, and mortality. Multiple covariates including demographic data, cause of PPH, types of delivery, hemodynamic stability, presence of disseminated intravascular coagulation (DIC), blood transfusion, angiographic findings, and embolized vessels were used in multivariate analyses to determine predictive factors associated with failed embolization. Results: A total 23 embolization procedures failed to achieve hemostasis (9.3%). The patients subsequently underwent hysterectomy (n⫽10), repeat embolization (n⫽9), remnant placenta evacuation (n⫽2), and vaginal laceration repair (n⫽2) for persistent bleeding. Eight patients (34.8%, 8/23) suffered from major complications including extremity paresthesia (n⫽3), cerebral ischemia (n⫽3), and pelvic abscess (n⫽2). One patient died of hypovolemic shock (4.3%, 1/23). DIC was independently associated with failed embolization (P⫽0.004, OR 0.219, 95% CI 0.078-0.621). Conclusion: Failed pelvic arterial embolization for PPH is not uncommon and frequently associated with significant morbidity and mortality. DIC is a major predictive factor for failed embolization.
10:46 AM
Abstract No. 260
Long term outcomes in treatment of pelvic congestion syndrome with venous embolization T. Morgan1, H.M. Richard, III1, R.P. Marvel2; 1 Radiology, University of Maryland, Baltimore, MD; 2 OB/GYN, The Center for Pelvic Pain, Annapolis, MD Purpose: To assess whether there is long term improvement in both symptoms and functionality of women following treatment of pelvic congestion syndrome with embolization. Materials and Methods: Over a 10 year period, 61 patients, average age 32 (range 17-66), were treated for pelvic congestion syndrome with ovarian and iliac vein embolizations at a single institution. Pretreatment pain assessment was routinely performed using the VAS, Chronic Pain Index, short form McGill (SFMcGill) pain questionnaires and Sf-12 v 2 QOL questionnaires. Following, IRB approval, a review of the medical record was performed to collect the pretreatment surveys. A letter was sent to all patients in the study via the US postal service requesting they complete a secure internet based version of the VAS, Chronic Pain Index, SF-McGill and Sf-12 v 2 using an assigned patient ID number. Results were collected and pretreatment versus post treatment scoring for both surveys were compared. Long term improvement was defined as 50% reduction in the pain score on VAS, improvement in the Chronic Pain Index, SF-McGill or SF-12. Surgical and gynecological medical histories as well as clinical follow up were also reviewed. Results: 41 patients pretreatment SF-Mcgill score and 38 patients pretreatment Sf-12 v 2 scores were available for review. Average time to follow up questionnaire was 5.4 year (range 10years to 8months). Post-treatment SF-McGill and SF-12 v 2 scores were completed by 29 patients. Average times for completed questionnaires was 3.8 years (range 1.1 to 6.5 years) Of the 19 patients with both pre and post treatment scores available, 11 post scores decreased and 8 scores increased compared with the pretreatment score. Thus 57% of patients had durable long-term relief of their chronic pelvic pain 3.8 years after their procedure. Conclusion: In women meeting criteria for pelvic congestion syndrome who undergo ovarian and internal iliac venous embolizations, durable long term relief is possible in the majority of patients. Recurrent pain continues to be a problem in some patients and this speaks to the multifactorial nature of chronic pelvic pain.
Scientific Session 䡲 JVIR
primary postpartum hemorrhage: a prospective study of 61 cases
WEDNESDAY: Scientific Sessions
D. Zhou1,2, L. Shen2, Y. Jin2, S. Bennet1, W. Wang1, G. McLennan1; 1Imaging Institute, Section of Interventional Radiology, Cleveland Clinic, Cleveland, OH; 2Department of Interventional Radiology, Nanjing Medical University Affliated Suzhou Hospital, Suzhou, China Purpose: To evaluate the efficacy and safety of selective arterial embolization (SAE) with fibrin glue compared to conventional gelatin sponges in the treatment of primary postpartum hemorrhage (PPH). Materials and Methods: From January 2006 to December 2010, 61 women with severe PPH underwent SAE (uterine artery and/or anterior division of the internal iliac artery) after failure of first-line uterotonic treatment or hysterectomy (1 patient). Fibrin glue group (FG) was used in 32 cases while gelatin sponge (GS) was used in 29 cases. Clinical success, defined as not requiring additional embolization or surgery was compared between groups. Complications and reduction in post treatment menstruation were evaluated between groups based upon patient interviews. Results: The blood loss in the FG group was 2428 ⫾ 1249 ml and 2525 ⫾ 1691 ml in the GS group. The three main causes of PPH included uterine atony (FG n⫽ 18 vs GS 14), placenta accreta/ percreta (6 vs 9), and placenta previa (4 vs 3). Six patients had a previous cesarean section in FG group and 5 in GS group. The clinical success rate of FG group was not significantly different from GS group (90.6% vs 86.2%, p⫽0.70), Seven patients were considered to be clinical failures (FG ⫽ 3, GS ⫽ 4); six required additional treatment for bleeding cessation to be achieved, which was through either hysterectomies (FG ⫽ 3, GS ⫽ 2) or with re-embolization (GS group ⫽ 1); and one patient died (GS). 31.0% (9/29) of GS patients and 12.5%(4/32) of FG patients had pain (p⫽0.036). In GS group, one woman had distal embolization to the leg. Of the 55 patients who did not undergo a hysterectomy, 49 had follow-up evaluations (FG ⫽ 25, GS ⫽ 23). Menstruation resumed in all 49 patients within 63 ⫾ 18 days in the FG group and 67 ⫾ 17 days in the GS group (F⫽0.12, p⫽0.73). Menstrual bleeding decreased in amount and frequency in 37.5% (3/28) GDS and 15.6% (5/32) FG patiens (p⫽0.20). Conclusion: SAE with fibrin glue is as effective as SAE with gelatin sponge. There is less post procedure pain with fibrin glue.
10:38 AM
Abstract No. 259
Pelvic arterial embolization in treatment of postpartum hemorrhage: clinical outcomes and predictive factor for failed embolization Y. Kim, C. Yoon, N. Seong, Y. Woo, Y. Kim; seoul national university bundang hospital, Seongnam-si, Republic of Korea Purpose: This study aims to evaluate clinical outcomes of failed pelvic arterial embolization in treatment of postpartum hemorrhage (PPH) and to determine predictive factors associated with failed procedures. Materials and Methods: Two hundred forty-six consecutive patients (age range 22-41 years; mean 33 years) who underwent pelvic arterial embolization for PPH were enrolled in this retrospective study. The medical records and imaging studies were reviewed to evaluate the incidence of failed embolization, subse-
quent intervention, complication, and mortality. Multiple covariates including demographic data, cause of PPH, types of delivery, hemodynamic stability, presence of disseminated intravascular coagulation (DIC), blood transfusion, angiographic findings, and embolized vessels were used in multivariate analyses to determine predictive factors associated with failed embolization. Results: A total 23 embolization procedures failed to achieve hemostasis (9.3%). The patients subsequently underwent hysterectomy (n⫽10), repeat embolization (n⫽9), remnant placenta evacuation (n⫽2), and vaginal laceration repair (n⫽2) for persistent bleeding. Eight patients (34.8%, 8/23) suffered from major complications including extremity paresthesia (n⫽3), cerebral ischemia (n⫽3), and pelvic abscess (n⫽2). One patient died of hypovolemic shock (4.3%, 1/23). DIC was independently associated with failed embolization (P⫽0.004, OR 0.219, 95% CI 0.078-0.621). Conclusion: Failed pelvic arterial embolization for PPH is not uncommon and frequently associated with significant morbidity and mortality. DIC is a major predictive factor for failed embolization.
10:46 AM
Abstract No. 260
Long term outcomes in treatment of pelvic congestion syndrome with venous embolization T. Morgan1, H.M. Richard, III1, R.P. Marvel2; 1 Radiology, University of Maryland, Baltimore, MD; 2 OB/GYN, The Center for Pelvic Pain, Annapolis, MD Purpose: To assess whether there is long term improvement in both symptoms and functionality of women following treatment of pelvic congestion syndrome with embolization. Materials and Methods: Over a 10 year period, 61 patients, average age 32 (range 17-66), were treated for pelvic congestion syndrome with ovarian and iliac vein embolizations at a single institution. Pretreatment pain assessment was routinely performed using the VAS, Chronic Pain Index, short form McGill (SFMcGill) pain questionnaires and Sf-12 v 2 QOL questionnaires. Following, IRB approval, a review of the medical record was performed to collect the pretreatment surveys. A letter was sent to all patients in the study via the US postal service requesting they complete a secure internet based version of the VAS, Chronic Pain Index, SF-McGill and Sf-12 v 2 using an assigned patient ID number. Results were collected and pretreatment versus post treatment scoring for both surveys were compared. Long term improvement was defined as 50% reduction in the pain score on VAS, improvement in the Chronic Pain Index, SF-McGill or SF-12. Surgical and gynecological medical histories as well as clinical follow up were also reviewed. Results: 41 patients pretreatment SF-Mcgill score and 38 patients pretreatment Sf-12 v 2 scores were available for review. Average time to follow up questionnaire was 5.4 year (range 10years to 8months). Post-treatment SF-McGill and SF-12 v 2 scores were completed by 29 patients. Average times for completed questionnaires was 3.8 years (range 1.1 to 6.5 years) Of the 19 patients with both pre and post treatment scores available, 11 post scores decreased and 8 scores increased compared with the pretreatment score. Thus 57% of patients had durable long-term relief of their chronic pelvic pain 3.8 years after their procedure. Conclusion: In women meeting criteria for pelvic congestion syndrome who undergo ovarian and internal iliac venous embolizations, durable long term relief is possible in the majority of patients. Recurrent pain continues to be a problem in some patients and this speaks to the multifactorial nature of chronic pelvic pain.