Background: Hepatic arteriovenous malformations (HAVMs) are rare congenital lesions consisting of multiple highpressure arteries feeding into low-pressure veins via a central nidus. Massive haemorrhage, portal hypertension and hepatic insufficiency can ensue. Endovascular embolization is increasingly a first line treatment method although there is no general consensus or guidelines on the most effective embolic agent or approach. We describe the novel treatment of two dogs with congenital hepatic AVMs using a modified version of the 'pressure cooker' technique often utilised in neurointervention with the DMSO-based PHIL embolic agent delivered via the DMSO compatible Scepter-XC dual lumen balloon catheter. Case presentation: Two paediatric dogs were diagnosed with hepatic AVMs. Both dogs presented with ascites and abnormal liver function tests. CT angiograms revealed hepatic arterio-portal malformations arising from an enlarged celiac artery. Selective catheterisation of the artery supplying the AVM was achieved via a femoral artery approach. A Scepter XC dual-lumen compliant balloon microcatheter and Traxcess 0.014 guidewire combination was advanced to the nidus via through the 5Fr guide catheter towards the nidus. Inflation of the balloon occluded arterial inflow and PHIL was injected under continuous fluoroscopic screening until the PHIL embolic agent penetrated into the draining portal vein beyond the nidus. In patient 1, normal portal venous waveform was restored with reversal of severe hepatic insufficiency. Whilst there was initial improvement post-operatively in patient 2 with normalisation of portal vein pressures and flow, opening of collateral nidus vessels re-established the high-pressure communication, and euthanasia was elected by the owner. Conclusions: The 'pressure cooker' technique is a safe and efficacious approach to the treatment of canine HAVMs. The novel use of PHIL and the Scepter XC balloon catheter has several advantages over conventional endovascular approaches. Translational application to human paediatric interventions for similar conditions where embolic and contrast agent volume constraints are similar can be considered.
Objective
Surgical technique for loop electrosurgical excision procedure (LEEP) and cold knife cone (CKC) emphasizes a uniform specimen, but sequelae of specimen fragmentation are not established. We evaluated outcomes between fragmented and unfragmented excisional biopsy specimens.
Materials and Methods
Loop electrosurgical excision procedure and CKCs from January 2010 to October 2013 were reviewed. Intraepithelial lesion grade, fragmentation, margin, and Endocervical curettage status were analyzed. Adenocarcinoma in situ and cancer were excluded. Repeat procedures during the study period were included in follow-up. Loop electrosurgical excision procedures with top hat with no separate fragments were analyzed independently versus those with fragmented LEEP and/or top hat. Indeterminate margin was defined as inconclusive or unevaluable margin, or intraepithelial lesion in unidentifiable margin or fragment. Outcomes involved residual or recurrent disease and repeat procedures for intraepithelial lesion. χ2 was used for statistical analysis.
Results
Fragmented specimens were more likely to have any positive margin (p = .01), multiple positive margins (p < .001), and indeterminate margin (p < .001) than unfragmented specimens. There was no significant difference in rates of positive, insufficient, or high-grade Endocervical curettage (p = .74, 0.54, 0.92). Patients with fragmented specimens were more likely to have high-grade lesion recurrence in the following 3 years (p = .04) versus patients with index unfragmented specimens, though not compared with those with unfragmented LEEP + top-hat cases. Overall rates of repeat LEEP/CKC or hysterectomy for dysplasia were not different (p = .56).
Conclusions
Fragmentation of LEEP and CKC specimens is associated with higher rates of positive margins, recurrent high-grade intraepithelial lesions, and indeterminate margins. These may cause diagnostic uncertainty, require closer follow-up, and increase cost with more visits and studies.
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