Postembolization syndrome: changes in white blood cell counts immediately after uterine artery embolization

Efficacy of High-Dose Dexamethasone in Reducing the Symptoms of Postembolization Syndrome Following Prostatic Artery Embolization: Results of a Double-Blind Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of a single perioperative dose of dexamethasone in reducing postembolization syndrome following prostatic artery embolization.

MATERIALS AND METHODS

We conducted a single-center double-blind randomized controlled trial from March 2021 to May 2022 (NCT04588857). Participants were randomized to receive either i.v. 24 mg dexamethasone or saline. The primary outcome measures were temperature, pain, and quality of life in the first 5 days following prostatic artery embolization. Sample size of 60 patients was needed for the assessment of primary outcomes. Participants were followed for 6 months and assessed for a variety of secondary outcome measures including inflammatory markers and lower urinary tract symptoms severity.

RESULTS

Due to lack of clinical effect and mild symptoms in the control group, the trial was terminated early. 31 participants (16 dexamethasone vs. 15 control) were enrolled and analyzed. A difference in mean temperature was observed on day 1 (37.23 ± 0.64 °C control vs 36.74 ± 0.41 °C dexamethasone, p = 0.02, 95% CI 0.09-0.89). Difference in pain (score out of 10) was seen only on day 5 (1.48 ± 1.2 control vs. 2.9 ± 2.24 dexamethasone, p = 0.04, 95% CI - 2.78-- 0.04). A difference in C-reactive protein values was observed on day 2 (108 [54-161] mg/l control vs 10 [5-33] mg/l dexamethasone, p < 0.01). No significant differences in other outcomes were observed. No side effects were recorded.

CONCLUSIONS

Twenty-four milligrams of dexamethasone bolus is safe but does not reduce postembolization syndrome following prostatic artery embolization.

Efficacy of intra-arterial lidocaine administration on pain and inflammatory response after uterine artery embolization for symptomatic fibroids

BACKGROUND

There have been conflicting outcomes regarding the use of lidocaine to reduce pain after uterine artery embolization (UAE).

PURPOSE

To investigate the efficacy of intra-arterial lidocaine injection for pain and inflammatory response control within 24 h of UAE for symptomatic uterine fibroids.

MATERIAL AND METHODS

Of 1530 patients who underwent UAE for uterine fibroids in 2007-2021, 5 mL of 1% lidocaine was injected into each uterine artery immediately after UAE in 23 patients. A disease-matched control group (n = 23) who did not receive intra-arterial lidocaine was generated from the same registry. The pain score, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and fentanyl consumption were compared before and after UAE. Complete infarction of the dominant fibroid was assessed using magnetic resonance imaging.

RESULTS

Significantly lower WBC count, CRP level, and NLR were noted 24 h after UAE in the lidocaine group. No statistically significant difference was noted in the pain score between groups at 0-24 h. The cumulative fentanyl dose administered during the first 24 h after UAE was not significantly different. After embolization, fibroid-related symptoms resolved in all patients. No significant difference was observed in the rate of complete infarction of the dominant fibroid.

CONCLUSION

Lidocaine administration immediately after UAE resulted in a significant reduction in the inflammatory response. However, such a difference in the inflammatory reaction did not contribute to significant reductions in pain scores or fentanyl consumption.

Transarterial chemoembolization for hepatocellular carcinoma: 2023 expert consensus-based practical recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post- procedural patient care.

Transarterial chemoembolization for hepatocellular carcinoma: 2023 Expert consensus-based practical recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post- procedural patient care.

General Management Considerations for Placenta Accreta Spectrum

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Transarterial Chemoembolization for Hepatocellular Carcinoma: 2023 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post-procedural patient care.

Uterine Artery Embolisation of Fibroids and the Phenomenon of Post-Embolisation Syndrome: A Systematic Review

Post-embolisation syndrome (PES) is a prevalent complication that occurs in patients following uterine artery embolisation (UAE) for the treatment of uterine fibroids. The aetiology of PES remains incompletely understood, although postulated to result secondary to tissue infarction resulting in release of inflammatory mediators. We followed PRISMA guidelines and performed a systematic review of studies of PES following UAE from inception to October 2022. Our published protocol was prospectively registered. Our search yielded 54 results. We reviewed 22 full texts, and nine articles were included. Observational studies comprised 6/9 relevant studies, with 5/9 retrospective design. The rate of PES was documented in 5/8 studies (excluding case report) with a reported incidence ranging from 4-34.6%. Five of the nine studies studies postulated that the aetiological basis of PES is inflammatory related. Further research is necessary to advance our understanding of PES to define the biological basis of the syndrome with more certainty and gain a consensus on peri-procedure management to reduce incidence and improve patient outcomes.

Ultrasound guided microwave ablation compared to uterine artery embolization treatment for uterine fibroids - a randomized controlled trial

OBJECTIVE

To evaluate the efficacy, feasibility and acceptability of microwave ablation (MWA) compared to uterine artery embolization (UAE) as treatment for uterine fibroids.

METHOD

A randomized controlled superiority trial, including premenopausal women 30-55 years, with symptomatic uterine fibroids without any single fibroid exceeding mean diameter of eight centimeters. Patients were randomized to receive microwave ablation, performed abdominally or vaginally, or to uterine artery embolization. The primary outcome was volume difference of the three largest fibroids at 6 months post treatment evaluated by magnetic resonance imaging (MRI) by a blinded radiologist analyzed by Mann-Whitney U-test. Secondary outcomes included symptom severity score (SSS), health related quality of life (HR-QoL), amount of menstrual bleeding, postoperative pain, length of hospitalization, need for additional treatment, adverse events and if patients would recommend the treatment to a friend.

RESULTS

Patients were recruited from 30 January 2017 to 12 September 2019, with a total of 17 patients treated in each group from May 2017 to December 2019. Superiority of MWA could not be established. The volume reduction was 41.8% (Interquartile range, IQR, 14-63) in the MWA group compared to 62.2% (IQR 34.9-80.1) in the UAE group (p = 0.29). Effects on symptoms, HR-QoL and acceptability did not differ between groups. Days of hospitalization and sick leave were significantly fewer in the MWA group (p < 0.001 and p = 0.001).

CONCLUSIONS

Although superiority of MWA could not be established, it is a promising technique for treating uterine fibroids. It was well tolerated and associated with lower use of health care resources. Trial registration: NCT02942537, www.clincialtrials.gov.

Successful minimally invasive surgery for postpartum retroperitoneal hematoma complicated by an infection: Two case reports

Introduction

and importance Postpartum retroperitoneal hematoma is a birth canal injury that is difficult to diagnose because of its invisibility. Secondary infections of these hematomas are rare, and their diagnostic and management strategies have not been fully elucidated. We present two cases of postpartum retroperitoneal hematomas with infection, which were successfully treated with minimally invasive surgery.

Case presentation

Case 1 was of a 2X-year-old woman who presented with complaints of fever; a provisional diagnosis of chorioamnionitis and Streptococcus pyogenes-induced sepsis was made. Case 2 was of a 3X-year-old woman who underwent uterine artery embolization and manual removal of the placenta for suspected placenta accreta. Both cases were diagnosed with adnexal hematomas, and antibiotic therapy failed in both patients. Therefore, we performed exploratory laparoscopy and made a diagnosis of retroperitoneal hematomas with infection; laparoscopic drainage resulted in rapid resolution of the clinical symptoms and abnormal blood test results.

Clinical discussion

Once an abscess develops, antibiotic treatment has a limited effect, and surgical drainage should be performed. Management of retroperitoneal hematomas is difficult, especially when complicated by an infection.

Conclusion

Minimally invasive procedures involving laparoscopy could be beneficial for the management of postpartum retroperitoneal hematomas complicated by an infection.

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Postpartum retroperitoneal hematoma is difficult to diagnose.

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Secondary infections of these hematomas are rare.

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The diagnosis and management strategies have not been fully elucidated.

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Management of retroperitoneal hematomas complicated by infection is challenging.

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Laparoscopy helps manage postpartum retroperitoneal hematomas with infection.

Efficacy of dexamethasone in reducing the postembolisation syndrome in men undergoing prostatic artery embolisation for benign prostatic hyperplasia: protocol for a single-centre, randomised, double-blind, placebo-controlled trial-the 'DEXAPAE' study

INTRODUCTION

Postembolisation syndrome (PES) is the most common side effect of vascular embolisation of solid organs. Although prophylactic corticosteroids are known to reduce the incidence and severity of PES, no trials investigating their efficacy have been conducted in men undergoing prostatic artery embolisation (PAE). We postulate that steroids can have a similar effect in reducing PES after PAE. This paper describes the rationale and detailed protocol for a randomised controlled trial evaluating the efficacy of dexamethasone (DEXA) in reducing PES after PAE.

METHODS AND ANALYSIS

In this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 60 individuals undergoing PAE for benign prostatic hyperplasia. Participants will be randomised to receive IV DEXA (24 mg) or placebo (saline). The primary outcomes will be postprocedural fever, pain and quality of life. The secondary outcomes will include postprocedural nausea, postprocedural medicine usage, laboratory parameters (C reactive protein, prostate-specific antigen) and early PAE results.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Danish Committee on Health Research Ethics in the Capital Region (H-20025910). The results from this trial will be disseminated through publication in peer-reviewed journals and national and international presentations.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT04588857; EudraCT number: 2020-000915-53.

Nonspherical Polyvinyl Alcohol Particles versus Tris-Acryl Microspheres: Randomized Controlled Trial Comparing Pain after Uterine Artery Embolization for Symptomatic Fibroids

Background Data are limited regarding comparison between nonspherical polyvinyl alcohol (PVA) particles and tris-acryl gelatin microspheres (TAGM) in uterine artery embolization (UAE). Purpose To compare pain after UAE with PVA versus TAGM for treatment of symptomatic fibroids. Materials and Methods In this randomized clinical trial, participants were assigned to be administered nonspherical PVA (355-550 μm) or TAGM (500-700 μm). Both groups were administered fentanyl-based intravenous patient-controlled analgesia during the first 24 hours after UAE and rescue analgesics. Neutrophil-to-lymphocyte ratio was measured to assess inflammatory response. Contrast-enhanced MRI 1 day after UAE was used to evaluate dominant fibroid necrosis and ischemia of normal myometrium. Symptom severity score and health-related quality-of-life score were assessed before and 3 months after UAE. Variables measured over time were analyzed by using the generalized estimating equation method. Results A total of 54 participants (mean age, 44 years ± 4 [standard deviation]) were evaluated (27 participants in each group). Although pain scores and fentanyl dose were not different during the first 24 hours, use of rescue analgesics was higher in the PVA group (33% vs 11%; P = .049). After embolization, symptom severity score and health-related quality-of-life score were not different between groups (symptom severity score: 16 [interquartile range, 6-22] for PVA vs 19 [interquartile range, 9-34] for TAGM, P = .45; health-related quality-of-life score: 93 [interquartile range, 80-97] for PVA vs 89 [interquartile range, 84-96] for TAGM, P = .41). Changes in neutrophil-to-lymphocyte ratio from before to 24 hours after UAE were greater in the PVA group (3.9 [interquartile range, 2.7-6.8] for PVA and 2.5 [interquartile range, 1.5-4.6] for TAGM; P = .02). Rates of complete dominant fibroid necrosis were not different between groups, but transient global uterine ischemia of normal myometrium was more frequent in the PVA group (44% vs 15%; P = .04). Conclusion When used in uterine artery embolization, polyvinyl alcohol particles and tris-acryl gelatin microspheres resulted in similar pain scores and fentanyl dose. Polyvinyl alcohol resulted in a greater inflammatory response, higher rates of rescue analgesic use, and more frequent transient global uterine ischemia. © RSNA, 2020 See also the editorial by Spies and Frenk in this issue.

Postembolization Syndrome after Prostatic Artery Embolization: A Systematic Review

Postembolization syndrome (PES) is the most common side effect of vascular embolization of solid organs. The aim of this review was to determine the incidence of PES and its individual components after prostatic artery embolization (PAE). A systematic review with a pre-specified search strategy for PubMed, Embase, Web of Science and Cochrane Library was performed according to PRISMA guidelines. Studies in English regarding PAE in humans with 10 or more participants were eligible for inclusion. No restrictions on participant demographics or PAE technique were imposed. The search returned 378 references, of which 32 studies with a total of 2116 patients met the inclusion criteria. The results for overall PES frequency and individual PES components were presented as median (interquartile range, (IQR)). Overall median PES frequency was 25.5% (12.5–45.8). The two most frequent individual PES components were dysuria/urethral burning and local pain, with a median frequency of 21.7% (13.8–33.3) and 20% (5.4–29.4), respectively. Most outcome measures were characterized by a marked lack of uniformity and inconsistency in reporting across studies. Development of a uniform reporting system would help the clinicians recognize and treat PES accordingly.

Basic embolization techniques: tips and tricks

Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.

Uterine-sparing management of pyomyoma after uterine fibroid embolization

Uterine fibroid embolization (UFE) is an increasingly popular treatment for uterine fibroids. One extremely rare complication after fibroid embolization is pyomyoma, which is the localized infection of the leiomyoma after embolization. Only 10 cases of pyomyoma after UFE have been reported in the literature. We present a case of delayed submucosal pyomyoma identified on computed tomography after 42 days post-UFE. While the majority of previously reported cases were managed by hysterectomy, our patient was treated with a uterine-sparing hysteroscopic transcervical approach. A high level of clinical suspicion is necessary to diagnose this complication after UFE to avoid major morbidity. Submucosal pyomyomas offer a favorable anatomical location easily accessible by hysteroscopy and a conservative approach may be sufficient to manage this complication.

Uterine Artery Embolization in Patients With Autoimmune Disease: A Matched Case-Control Study

OBJECTIVE. The purpose of this study is to investigate the safety of uterine artery embolization (UAE) for symptomatic leiomyomas in patients with autoimmune disease. MATERIALS AND METHODS. Of 1183 patients who underwent UAE for symptomatic leiomyomas, nine patients (mean age, 42.6 years; range, 34-49 years) with autoimmune disease were included in this study. An age- and disease-matched control group (n = 8) was randomly generated from our patient registry to compare the effectiveness and safety of UAE in patients with autoimmune disease. Volume reduction rates of the uterus and dominant leiomyoma and the change in C-reactive protein (CRP) levels before and after UAE were compared. RESULTS. Except for one patient who had Takayasu arteritis and indiscernible uterine arteries on angiogram, UAE was technically successful in both groups. All of the patients who underwent technically successful UAE experienced improvement or resolution of symptoms (16/16; 100%). Complete necrosis of dominant fibroids was achieved in all patients (16/16; 100%). Although there was no significant difference in the mean initial CRP level before UAE (0.4 ± 0.14 mg/L vs 1.06 ± 1.26 mg/L; p = 0.067), it was significantly higher in the autoimmune group 1 day after UAE (1.23 ± 0.6 mg/L vs 9.54 ± 6.63 mg/L; p = 0.001). There was no significant difference in the volume reduction rates of uterus and dominant leiomyoma. In the autoimmune group, there was one major adverse event that was not related to underlying disease. CONCLUSION. In patients with autoimmune disease, UAE could be considered for symptomatic leiomyomas, as long as the underlying disease is well controlled.

Prophylactic uterine artery embolization in second-trimester pregnancy termination with complete placenta previa

Objective

This study was performed to assess whether prophylactic uterine artery embolization (UAE) is beneficial for second-trimester abortion with complete placenta previa (CPP).

Methods

Patients with CPP who underwent second-trimester pregnancy termination by labor induction with or without UAE from January 2010 to January 2018 were retrospectively reviewed. In total, 25 patients were eligible for analysis. The primary outcomes were the abortion success rate and bleeding volume, and the secondary outcomes were the induction-to-abortion time, length of hospital stay, and complications.

Results

CPP occurred in all 25 patients. Fifteen patients underwent prophylactic UAE (UAE group) and 10 did not (control group). Abortion was successful in 13 of 15 (86.7%) women in the UAE group and in 9 of 10 (90.0%) women in the control group. There was no significant difference in the bleeding volume or induction-to-abortion time between the two groups. The hospital stay was longer and pyrexia was more common in the UAE than control group.

Conclusion

Prophylactic UAE did not markedly improve the outcomes of second-trimester abortion in patients with CPP. Conversely, it may increase the risk of complications and prolong the hospital stay.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy of single-dose dexamethasone in reducing post-embolization syndrome in patients undergoing uterine artery embolization

Background

Uterine artery embolization (UAE) is a minimally invasive technique well established for treating symptomatic uterine fibroids. However, the post-procedure recovery for UAE involves a notable inflammatory process in response to ischemia known as post-embolization syndrome (PES). PES encompasses transient leukocytosis, low-grade fever, and can result in readmission of up to 10% of patients. In surgical settings, multiple studies have demonstrated the efficacy of glucocorticoids in reducing inflammation and associated pain. However, this approach has not yet been assessed in predominantly ischemia-driven PES.

Methods

This paper describes the protocol of a prospective randomized, double-blind, placebo-controlled, multi-center trial to test the efficacy and safety of single-dose dexamethasone on inflammatory responses, pain, nausea, and readmission rates after UAE. The study will enroll pre-menopausal patients between 25 and 55 years (planned enrollment, n = 60) with MRI confirmed symptomatic fibroids. Patients will be randomly allocated into two groups: single-dose intravenous dexamethasone plus standard of care or placebo (normal saline) plus standard of care.

Results

The primary endpoint is the patient pain score 4 h following the UAE procedure. Secondary endpoints include pain scores at 7 h and 24 h following UAE; narcotic usage in the first 24 h following UAE; and serum inflammatory markers (white blood cell count, C-reactive protein [CRP], interleukin-6 [IL-6], and cortisol) 24 h after UAE.

Conclusion

Given the high incidence of post-procedure pain and difficulty with pain control after uterine artery embolization, results of this trial may directly influence the standard of care in perioperative management of patients undergoing UAE.

Prevention and management of infectious complications of percutaneous interventions

Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.

[Postpartum hemorrhage by vaginal laseration: new case and improved management]

We describe a case of uterine necrosis, following Gelitaspon(®) embolization for postpartum hemorrhage resulting from vaginal laceration. Previous cases published help to improve the safety of this effective method by showing the risk factors, as particles sizes, ultraselective embolization, prevention of infection. Controlling bleeding by surgery is the priority when hemorragy is due to laceration without uterin atony. In case of failure, embolization is an option which should be proposed without delay. Uterine necrosis should be suspected in case of postembolization septic syndrome.

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

OBJECTIVE

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

METHODS

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

RESULTS

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

CONCLUSION

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Complications of percutaneous procedures

Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures.