Recurrent embolization after

To reduce the risk of death, recurrent Ml, and thromboembolic events such as stroke or systemic embolization after Ml. 

Fig. 5.44a-d. A 39-year-old male, SAH 2 years previously, second recurrent aneurysm after embolization with bare coils (a) after hydrogel-coil-embolization (b), and 6 month FU with a stable result (c). d ToF-MRA after 2 years showed stable aneurysm occlusion... 

The prognosis of hospitalized patients tends to be worse than that of patients in the population at large because mild strokes are more likely to be cared for at home. In the community, about 20% of all patients with first-ever stroke are dead within a month. Deaths in the first few days are almost all caused by the brain lesion itself Deaths after the first week are more likely to be indirect consequences of the brain lesion, such as bronchopneumonia, pulmonary embolism, coincidental cardiac disease or recurrence. 

Retardation of clotting is important in blood transfusions, to avoid thrombosis after surgery or from other causes, to prevent recurrent thrombosis in phlebitis and pulmonary embolism. and to lessen the propagation of clots in the coronary aitcries. This retardation may be accomplished by agents that inactivate thrombin (heparin) or substances that prevent the fotmation of prothrombin in the liver (the coumarin derivatives and the phenylindanedione derivatives). 

Heit JA, Mohr DN, Silverstein MD, et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism A population-based cohort smdy Arch Intern Med 2000 160 761—768. 

Hepatic arterial bland and chemo-embolization have also been utilized. This therapy is based on the anatomic vascular distribution of the blood supply for hepatic tumors. The hepatic artery serves tumors in the liver almost exclusively while the portal vein serves normal hepatic parenchyma. There is some crossover but it is only approximately 10%. Bland embolization uses particles placed in the hepatic artery only while chemoembolization mixes these particles with a variety of chemotherapeutic agents and lipiodol, an iodinated poppy seed oil, which has been shown to increase the uptake into the cell via a pump in the cell wall. This therapy has been utilized for the last 20 years but eventual re-growth and recurrence have also uniformly occurred. Repeated embolizations are necessary to keep the disease in check and to palliate the patient s symptoms. The mean response to embolization is approximately 12-18 months with eventual occlusion of the hepatic arterial supply to the tumor after multiple embolizations. Response to embolotherapy has been dramatic for palliation of symptoms, with 63% of patients reporting a reduction in symptoms and an objective response seen on CT to be 76% either partial or minimal response, with an additional 16% reporting stable disease [4]. The embolotherapy will rid the patient of much of their tumor burden but isolated islets of viable tumor will remain after the procedure, accounting for the resurgence of disease. 

Israel and Diamond (1962) were the first to report after nitrofurantoin a case of recurrent pulmonary infiltration with eosinophilia and pleural exudate taking the course of pulmonary embolism. 

After embolization of a uterine fibroid clinical follow-up might be sufficient. However, to prevent an early recurrence, early MR controls might be necessary. Pain control following embolization... 

Marret H, Alonso AM, Cottier JP, Tranquart F, Herbreteau D, Body G (2003) Leiomyoma recurrence after uterine artery embolization. J Vase Interv Radiol 14 1395-1399... 

Ten years after Ravina et al. first introduced the concept of embolization as a definitive therapy for symptomatic fibroids, uterine fibroid embolization (UFE) is accepted as a safe alternative to surgical treatment of fibroid tumors. Technique and materials have been greatly refined. Much progress has been made in our understanding of fibroid vasculature, management of postoperative pain and complications, and causes of treatment failure. According to the literature, the failure rates vary between 6% and 14% [1,2] however, there is still some confusion as to how to define success, failure or recurrence. In this chapter, we discuss the causes of failure after UFE and the different options available to minimize them. 

Early recurrence of symptoms can occur when uterine artery embolization is performed on patients with adenomyosis (please see Chap. 10.4). Uterine artery embolization for adenomyosis is reported to be effective to control the bleeding initially [22,23] however, this clinical success is short-term. There is a high rate of clinical recurrence after embolization of the uterine artery for adenomyosis. In a recent study by Pelage et al, 44% of the patients required an additional treatment, including hysterectomies in 28% of the cases [24]. 

Late recurrence is observed when new fibroids occur usually 5 years or later after embolization [26]. MRI may be useful to detect new fibroids actually even before the patient s symptoms worsen [27]. 

Recently, two minimally invasive therapies have been introduced to treat uterine fibroids. High frequency focused ultrasound and transvaginal paracervical clamping of the uterine arteries have been reported in the management of symptomatic uterine fibroids [10]. From our own experience with the use of uterine fibroid embolization, we know that unless complete devascularization of all identified fibroids is obtained after these therapies, the results in terms of recurrence will not be better than after myomectomy and maybe higher than after embolization. 

Clinical outcomes appear similar when the internal iliac veins are routinely occluded. Venbrux et al. (1999) followed 56 women for a mean of 22.1 months after embolization with coils and sodium morulate [36]. The internal iliac veins were also occluded in 43 of 56 patients at a separate procedure 3 to 10 weeks after ovarian vein embolization. The technical success rate was 100%. Three patients developed recurrent varices, two of whom were treated with repeat embolization. Using visual analogue scales to measure pain, a mean 65% decrease in VAS score was recorded. Two patients (4%) reported no change in their symptoms, no patients had worsening of their pain after embolization. 

Regardless of the route chosen, the most important task is to access the channel or the sac. It is critical to disrupt the network between the involved vessels. This is more important than occluding any one vessel or even embolizing the endoleak sac (Figs. 14.3, 14.4). This explains the high rate of recurrence after IMA embolization alone (Fig. 14.4) compared to translumbar embolization for type II endoleak in one report [44]. 

During the follow-up of patients with high-llow priapism, we recommend color Doppler ultrasound 1-2 months after embolization to confirm the absence of recurrent fistula. Recanalization of the em-bolized cavernosal artery can be observed also when non-reabsorbable embolization material has been used (Savoca et al. 2004). In patients with erectile dysfunction, the study should be performed after in-tracavernosal prostaglandin injection to determine whether the functional impairment is caused by insufficient penile blood flow or not. 

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