Embolization Reduces Bleeding in Gynecologic Surgery


CME NUGGETS

Ed Susman

Mr. Susman is a freelance medical writer based in Florida, USA. He travels worldwide to report from medical conferences, writing regularly for wire services, internet websites, and medical journals such as the Journal of the National Cancer Institute and AIDS.

For comments, edwardsusman@cs.com


Hollywood, Florida – Women who undergo surgery to remove fibroids and want to preserve fertility may experience less blood loss and spend less time in the operating rooms if they undergo uterine embolization prior to surgery, researchers reported here at the 32nd International Symposium on Endovascular Therapy.

The mean blood loss in the 49 women who opted to undergo trans-catheter uterine artery embolization using Gelfoam was 326.81 mL compared with 545.61 mL in the 41 women who underwent myomectomy without going through the embolization procedure (p=.024), reported Pasteur Rasuli, MD, associate clinical professor of diagnostic imaging at the University of Ottawa, Ontario, Canada.

“Uterine artery embolization as carried out by selective catheterization of both uterine arteries and embolizing them with Gelfoam particles in the morning of the scheduled myomectomy procedure,” Dr. Rasuli explained.

However, the operative time among the women who did receive embolization was a mean 78.36 minutes compared with an operative time of 183.51 minutes in the non-embolized group (p <.0001), Dr. Rasuli reported in his poster presentation last January 23.

The mean fibroid volume was similar in both the women who had the embolization procedure and those who did not, he noted. In the embolized group, mean fibroid volume was 527.6 cc3. In the women who were not embolized, the mean fibroid volume was 540.17 cc3. The mean number of fibroids in embolized group was 2l96; in the non-embolized group the mean number of fibroids was 3.96.

The women who were not embolized had a short time in hospital – 3 days, compared to 3.5 days for the women who received the embolization treatment.

“Pre-myomectomy uterine embolization significantly reduces blood loss and operative time while preserving fertility,” the researchers suggested.

The researchers added, “Several complications associated with myomectomy are on the rise, likely due to increase in pregnancies at later ages and progressively higher number of myomas being discovered in this older age group that are also larger in size.

But because there are more pregnancies attempted at later ages, there may be more and larger myomas, which in turn, can increase bleeding during surgery.

Balloon comparison

In a rare study at the ISET meeting – in which two devices are directly compared head-to-head – researchers suggested that treatment of lesions of the superficial femoral artery with low-dose and highdose drug-coated balloons have similar outcomes.

In the study, 66 percent of patients treated with the Ranger drug-coated balloon, an investigational device in the United States, achieved primary patency after 24 months of follow-up compared with 60 percent of patients who were treated with the IN.PACT drug-coated balloon (p=.5708), reported Michael Jaff, MD, president of Newton-Wellesley Hospital and professor of medicine at Harvard School of Medicine, Boston, Massachusetts.

“Low-dose Ranger drug-coated balloon has demonstrated patency similar to a higher-dose drug-coated balloon through 2 years in the COMPARE Pilot trial,” he said in his oral, late-breaker presentation.

The Ranger drug-coated balloon is infused with a 2 microgram/mm2 dose of paclitaxel; the IN.PACT dose of paclitaxel is 3.5 microgram/mm2. Both drug-coated balloon catheter delivered devices are approved in Europe.

The study was conducted at 15 centers in Germany, with 76 patients being assigned to treatment with the IN.PACT Admiral device (Medtronic), and 74 patients assigned to treatment with Ranger (Boston Scientific).

The average lesion length in the Ranger patients was 117.4 mm compared with an average length of 122.3 mm among the IN.PACT patients, a non-significant difference (p=.8), Dr. Jaff reported. Other lesions characteristics such as diameter stenosis – about 83 mm; reference vessel diameter – about 5 mm; minimal vessel diameter – about 0.8 mm; total occlusions – 39 percent of the Ranger patients and 44% of the IN.PACT patients; and total occlusion length – 110 mm among the Ranger patients with total occlusions and 95 mm among IN.PACT patients; and lesion classification, were not significantly different between the two groups of patients in the study.

At one year, Dr. Jaff reported that 85 percent of Ranger patients and 88 percent of IN PACT patients has achieved primary patency; at 710 days, 75 percent of Ranger patients and 77 percent of IN.PACT patients had maintained primary patency.

The investigator-sponsored study was sponsored by grant funding from Boston Scientific.

Just because you are 90

In another study at the meeting that features catheter-based minimally-invasive procedures, researchers said that the use of atherectomy or angioplasty in iliac and infra-inguinal critical limb ischemia patients 90 years ago or older appears to be accomplished with similar success to younger patients undergoing the procedures.

In studying procedures on this elderly population, Edward Gayou, MD, MPH, a resident in radiology at Ohio State University, Columbus, reported that interventionalist achieved technical success in 85.9 percent of the 42 patients, and there was no periprocedural mortality, and no periprocedural events.

He and colleagues noted in their poster presentation that other case series that considered nonagenarians indicated there were periprocedural mortality as high as 10% – which was in contrast to the current findings.

Dr. Gayou also noted that another literature reference found that when comparing outcomes with younger patient populations there were no major differences in adverse limb events, in amputation and in the need for re-intervention.

“Atherectomy and/or angioplasty is a safe and well-tolerated procedure in nonagenarians with critical limb ischemia,” he reported. “Further research is needed to determine long-term efficacy of endovascular arterial intervention in this age group.”

The patients included in the study were treated between 2012 and 2018. The average age of the patients was 92.4 years. There 29 women and 13 men in the study who underwent treatment on 57 limbs. The interventionalists utilized 93 standard angioplasties, 29 orbital atherectomies, 2 directional atherectomies, 6 aspiration thrombectomies and 4 laser atherectomies on 96 total lesions. During the treatment, 6 drug-coated stents and 32 non-drug coated stents were deployed.

Dr. Gayou reported that the most common complication was dissection, which occurred in 10.4% of the cases. Distal embolization occurred in 4 cases, and 3 of those cases occurred when the procedure was performed without distal protection. He reported that the majority of cases were performed with moderate sedation.

“Traditionally surgical bypass using an autologous saphenous vein has been considered first line therapy for critical limb ischemia associated with peripheral artery disease,” the researchers noted. “However, advances in endovascular intervention have led some to consider less invasive therapies as first-line treatment. Nonagenarians, in particular, are a patient cohort that presents a unique treatment challenge.” Previously, these therapies have been considered contraindications in the older patients, but the researchers noted that recent studies indicate that there may be more benefit from the procedures than risks in these patients.

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