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Management of the High-Risk Obstetric Patient

Acknowledgments The authors wish to acknowledge Kiang Hiong Tay, who contributed to this chapter in the previous edition. Peripartum hemorrhage (PPH) is reported as the most common maternal morbidity in developed countries and a major cause of death worldwide. Globally, postpartum hemorrhage may account for 25% of delivery-associated deaths. The incidence may be up to 20% of pregnancies beyond 18 weeks’ gestation. In the United States,…

Uterine Fibroid Embolization

Uterine fibroid embolization (UFE) was first reported in the United States in 1997 as a minimally invasive alternative to hysterectomy and myomectomy for treatment of fibroids. Since that time, its effectiveness has been confirmed by other investigators, including in major randomized comparative trials, and it has rapidly been incorporated into practice. In 2008, the American College of Obstetricians and Gynecologists acknowledged the effectiveness of UFE, stating…

Vascular Anatomy of the Pelvis

The rich vascular supply of the pelvis not only supports the structures contained within it, including the bladder, rectum, and reproductive organs, but also extends to the lower extremities. For a complete understanding of vascular anatomy as it pertains to the endovascular procedures of interventional radiology, it is useful to discuss the vascular structures in sections, from the bifurcation of the aorta and the inferior vena…

Management of Visceral Aneurysms

The entity of visceral artery aneurysms (VAAs) includes aneurysms of the splanchnic circulation and those of the renal artery. Aneurysms of the splanchnic circulation include aneurysms of the celiac trunk, superior mesenteric artery (SMA), inferior mesenteric artery or their branches. Although rare, their diagnosis remains clinically important because of the high mortality and potential complications associated with them. Splenic artery aneurysms (SAAs) are the most common,…

Splenic Embolization in Nontraumatized Patients

Embolization of the splenic artery has become established practice in the treatment of splenic hemorrhage following abdominal trauma since it was first described by Sclafani in 1981. There has also been a progressive expansion in the use of splenic artery embolization (SAE) in the nontrauma setting. Traditional surgical treatment with splenectomy for many of the nontrauma indications is now being challenged by the less invasive technique…

Management of Trauma to the Liver and Spleen

Trauma to the liver and spleen is usually the result of blunt abdominal injury caused by road traffic accidents or falls. Other important causes are penetrating injuries or iatrogenic trauma, most often during or after surgery. Liver or splenic injury may occur as isolated injuries, but also as part of combined trauma to the chest and abdomen, abdomen and pelvis, or trunk and extremities. Certain combinations…

Intervention in the Liver Transplant Patient

Since the first clinical attempt by Thomas E. Starzl in 1963, liver transplantation is now accepted as the gold standard treatment of advanced chronic liver disease, of irreversible hepatocellular failure, and for a selected group of patients with hepatocellular carcinoma. There were 7841 liver transplants performed in the United States in 2016 according to the Organ Procurement and Transplantation Network. Actual 1-, 3-, and 5-year survival…

Portal Vein Embolization

One of the prerequisites for partial hepatic resection is the presence of enough remaining functional liver parenchyma to avoid life-threatening postoperative liver failure. Therefore, the possibilities of curative resection of liver tumors are strongly dependent on the volume of the future remnant liver (FRL). In clinical practice, these possibilities are frequently limited when an extended hepatectomy is mandatory because the FRL is too small. The more…

Embolotherapy for the Management of Liver Malignancies Other Than Hepatocellular Carcinoma

Clinical Relevance Patients who have liver metastases that are not amenable to resection or ablation generally have poor survival rates. Liver metastases from neuroendocrine tumor (NET), sarcoma, colorectal cancer (CRC), melanoma, and pancreatic cancer can be treated using transarterial embolization (TAE) or transarterial chemoembolization (TACE). The normal liver ( Fig. 36.1 ) is mostly supplied by the portal vein, whereas hepatocellular carcinoma (HCC) and hypervascular metastases…

Transcatheter Embolization of Liver Metastases

The liver is an important site of metastatic disease for many primary malignancies, and liver metastases ( Figs. 35.1, 35.2, and 35.3 ) are a leading cause of cancer-related death. Two major mechanisms for disease spread to the liver have been proposed. The first is the “mechanical or hemodynamic” hypothesis, whereby circulating cancer cells are mechanically trapped in the liver, accounting for the predilection of gastrointestinal…

Chemoembolization for Hepatocellular Carcinoma

Clinical Relevance Hepatocellular carcinoma (HCC) is the most common primary liver cancer, ranking fifth for men and seventh for women as a source of primary malignancy. Cirrhosis secondary to chronic infection with hepatitis B and/or hepatitis C is the main risk factor for developing HCC. Nonalcoholic fatty liver disease–related cirrhosis is a rising risk factor in developed countries. Increasing incidence rates of HCC, in conjunction with…

Transvenous Pressure Measurements and Liver Biopsy

Transvenous Pressure Measurements Clinical Relevance Chronic inflammation of the liver results in hepatic fibrosis and leads ultimately to cirrhosis. Portal hypertension is the hallmark of liver cirrhosis and is defined as a portal pressure gradient (pressure gradient between portal vein and inferior vena cava [IVC]) of greater than 5 mmHg. The portal pressure gradient is considered clinically significant when greater than 10 mmHg. Portal hypertension is…

Renal Artery Embolization

Clinical Relevance Embolotherapy of the renal arteries was introduced into the portfolio of the interventional radiologist many years ago. It was most popular in the 1980s and 1990s when preoperative embolization of kidneys containing a renal cell carcinoma (hypernephroma) was widely used as a routine procedure in the belief that preoperative embolization might avoid tumor seeding during surgery. Because no oncological benefit has since been proved…

Renal Ischemia

Acute renal ischemia occurs because of a transient sudden drop in the total or regional blood flow to the kidney. Acutely diminished renal perfusion results in acute kidney injury. Impaired blood flow to both kidneys or to a solitary functional kidney can occur due to generalized hypoperfusion in cases of hypovolemia or to decreased cardiac output in acute cardiac decompensation, leading to acute renal failure. Acute…

Renal Vasculature

Acknowledgments The authors wish to acknowledge the contributions of authors Morvarid Alaghmand, Ali Noor, Aaron Reposar, Rishabh Chaudhari, and Ramy Khalil, who contributed to this chapter in the second edition. Understanding the vascular anatomy of the kidneys, ureters, adrenals, and bladder is essential for performing image-guided therapy. For example, a patient with a traumatic fistula between the renal artery and vein may benefit from transcatheter embolotherapy.…

Chronic Mesenteric Ischemia

Although chronic mesenteric ischemia (CMI) is a relatively uncommon entity due to the robust mesenteric arterial collateral circulation, detection of intestinal angina and CMI is of critical importance. If the diagnosis is overlooked or missed, acute mesenteric ischemia can result. Once acute mesenteric ischemia develops, patient mortality rates become extremely high. In addition, an accurate diagnosis and pretreatment noninvasive evaluation will facilitate treatment planning and affect…

Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a life-threatening vascular emergency that requires early diagnosis and intervention to adequately restore mesenteric blood flow and prevent fatal bowel necrosis. Causes include arterial embolus, which occurs most frequently (40%–50%), arterial thrombosis (20%–30%), venous obstruction (5%–18%) and nonobstructive causes (20%–30%). Clinical signs vary considerably and are nonspecific. Patients present with severe abdominal pain that is initially out of proportion to any…

Management of Lower Gastrointestinal Hemorrhage

Clinical Relevance Lower gastrointestinal (GI) hemorrhage (LGIH) is much less common than upper GI tract hemorrhage. The incidence of LGIH is approximately 20.4 cases per 100,000 adults per year. However, it is associated with a 10% mortality rate, and although less common than upper GI bleeding, it more often demands the specialized skills of the interventional radiologist. These cases are frequently less amenable to endoscopic management,…

Management of Upper Gastrointestinal Hemorrhage

Clinical Relevance Upper gastrointestinal (UGI) hemorrhage (UGIH) is a common medical problem, with 50,000–70,000 hospital admissions per year in the United Kingdom (UK). It is the second most common medical reason for transfusion after hematological conditions, accounting for 14% of all blood transfusions. Mortality is between 5% and 14% in the UK and North America. Around 15% of UGI bleeds occur in patients who are already…

Anatomy of Alimentary Tract Vasculature

Clinical Relevance An understanding of the vascular anatomy of the alimentary tract allows a wide range of therapeutic options for patients who traditionally were treated by open surgery. In addition to the use of catheter-directed embolotherapy and pharmacologic vasoconstriction for gastrointestinal (GI) hemorrhage, a knowledge of variant anatomy may prevent complications such as non–target organ embolization. For example, recognition of variant anatomy during hepatic artery chemoembolization…