Letters
to the
Editor
.
Potential Therapeutic Effect of Oil-soluble Contrast Media in Hysterosalpingography
with df=
From:
mussen
David
B. Spring
Oakland,
Kaiser
Permanente
Medical
Center
CA
Howard E. Barkan, DrPH Department of Nursing, Sonoma Sonoma,
State
University
April
1991
used.
Lindequist et al (1) and Rasthe pregnancy rates after hysterosalfour different contrast media (diatriioxaglate, and ethiodized poppy-
They
found
that
three
times
as many
patients became pregnant after HSG with oil-based contrast media than with water-based contrast media. If valid, these findings should guide our choice of contrast agents when evaluating infertile women for fallopian tube disorders. Several potential methodologic problems cause us to queslion the validity of their condusions (1,2). HSG findings are often used to guide the conduct of subsequent laparoscopy or other operative procedures. In some procedures, it may be necessary to introduce other materials through the fallopian tubes. Whether
other
procedures-either
laparoscopy
gery-were performed during women (regardless of whether dear from the artides (1,2). In addition,
This
the
statistic
was
(x2
significant
7.34,
=
the data presented by Lindequist et al (1) and Raset al (2), investigators in this country remain reluctant to advocate the use of oil-based contrast agents (4). We are organizing a multisite, nonexperimental, collaborative study to reexamine the therapeutic effect of all HSG contrast agents, including the sequence of multiple agents advocated by some (5), which also may encourage favorable outcomes in infertility others
with
this
common
interest
to
study.
of Radiology,
issue
et al (2) compared pingography (HSG) when zoate meglumine, iohexol, oil) were
agent.
.00676).
encourage join in our collaborative
mussen
seed
=
investigations. We wish to
CA
Editor: In the
oil-based
Despite
MD
of Radiology,
Department
an
1,P
authors
noted
or after HSG they became important
or open
lion Hospitals References 1. Lindequist ity
2.
3.
4. 5.
The medical
provided
editorial
S,Justesen
department
P, Larsen
C, Rasmussen
media:
of Kaiser
Founda-
a randomized
Diagnostic
F.
of hysterosalpingography:
complications
contrast
editing
assistance.
prospective
qual-
oil- versus waterstudy. Radiology
1991; 179:69-74. Rasmussen F, Lindequist 5, Larsen C,Justesen P. Therapeutic effed of hysterosalpingography: oil versus water-soluble contrast media-a randomized prospective study. Radiology 1991; 179:7578. Lee ET, Desu MM. A computer program for comparing K samples
with right-censored 321. Yoder IC, Hall DA. 157:675-683.
data. Comput
Programs
Hystemsalpingography
DeCherney
nancy
in the with
rate of diagnosis of underlying pathologic conditions HSG when oil- and water-soluble contrast media were used. Women examined with water-soluble contrast agents were almost twice as likely to have hydrosalpinx (diatrizoate, 22 of 104 patients; ioxaglate, 22 of 105 patients; iohexol, 26 of 105 patients) as were women examined with an oil-based agent (ethiozized poppy-seed oil, 13 of 103 patients). Bilateral hydrosalpinx almost always results in infertility if not treated. We adjusted the data from Figure 2 in the artide by Lindequist et al (1) to eliminate data concerning the potentially sterile women with bilateral or unilateral hydrosalpinx, and then reanalyzed the statistics. With both the x2 tabulation with the continuity correction and the survival statistic as described by Lee and Desu (3), we found even greater statistical differences in conception rates between women examined with conventional water-soluble contrast agents and women examined with ethiodized poppy-seed oil (x2 = 7.97, df = 1, P = .0048) and in term pregnancy rates of these women (x2 15.73, df = 1, P = .00007). The most important finding was the difference in term pregnancy rates of women examined with ethiodized poppy-seed oil and diatrizoate meglumine alone (x2 10.50, df = 1, P = .0014). Indeed, the driving force in the relative “therapeutic effect” suggested by Rasmussen et al (2) and Lindequist et al (1) appears to be the particularly low term pregnancy rates associated with use of the conventional agent diatrizoate meglumine. Of 315 women in whom no hydrosalpinx was found, 84 became pregnant. Women who did become pregnant were more than three times as likely to miscarry if they had been exammed with a water-based agent than if they had been examined
and
soluble
sur-
in any of the pregnant) is undifferences
ACknowledgment
1980;
AM, Kort H, Barney JB, DeVore oil-soluble hysterosalpingography 33:407-410.
rate with
Dr Lindequist
and colleagues
Biomed
1972; 2:315-
in the 1990s. AJR 1991; GR.
Increased pregdye. Fertil Steril
respond:
We appreciate Spring and Barkan’s interest in our artides cerning contrast media in HSG (1,2) and the opportunity respond to their comments.
conto
Several potential methodologic problems are stated, and the effects of laparoscopy or surgery performed after HSG on the pregnancy rates are suggested as one of the problems. Indeed, it would have been a real methodologic problem if a priori we
had changed the post-HSG procedure with regard to laparoscopy and/or surgery and, thus, introduced a bias that could have been an advantage or disadvantage for one or more of the contrast media groups. Only 12 of the patients who became pregnant in the 9-month follow-up period after HSG underwent laparoscopy or surgery 2 years after HSG. This does not explain the differences in post-HSG pregnancy rates. We found that 134 of our 398 patients with infertility zoate, n = 37; ioxaglate, n = 36; iohexol, n = 27; ethiodized poppy-seed oil, n = 34) underwent laparoscopy and/or gery in the 2-year follow-up period. This is in agreement
the finding that the prevalence duration of infertility, infertility
of all other
parameters
(diatrisurwith
(age,
status, temperature curve, the partner’s sperm quality, previous gynecologic diseases and surgery, and hormonal treatment before and after HSG) did not
show
statistically significant differences between the four congroups (1,2). We do not think that the calculations made by Drs Spring and Barkan alter the condusions of our study. The pregnancy trast
media
283
rate
after
with
HSG
diatrizoate
the estimated spontaneous the term pregnancy rate trizoate “driving
meglumine
associated
with
force”
meglumine is comparable pregnancy rate (1). It is true
was high
and
appears
low in the patients in those receiving
to be the high
oil. Conversely, the oil-based medium
the artery
receiving diaoil, but the
(term)
the high
to that
pregnancy
pregnancy
rate
rate
after
and without
About although
I minute warned
quently complained groin. We noticed suspecting rupture
design, and we have included one of the newest isomolar, nonionic dimer water-soluble contrast mediums, iotrolan. We hope to present the results of this new study at the 1992 RSNA scientific assembly. As indicated in our study of image quality (2), water-soluble contrast media were superior to oil-soluble contrast media in the depiction of the ampullary rugae; this may explain the different numbers of hydrosalpinx in the waterand oil-soluble groups. We agree that a bilateral hydrosalpinx, if untreated,
evacuated.
almost
always
results
lateral
hydrosalpinx
in infertility,
and that patients
can become
pregnant
after
with
HSG
a uni-
(1).
We look forward to seeing the results from the multicenter study organized by Spring and Barkan. We hope that it will be a randomized prospective trial with randomization in each center
to avoid
methodologic
the investigated
problems
population
such
and dinical
as differences
in
and radiologic
proce-
direct pressure on the aneuapplied for 20 minutes, after and the flow in the false aneu-
after compression was released, not to do so, coughed forcefully
could be a random phenomenon, although the statistics tell us that it probably is not. We are conducting further studies with the same prospective with
HSG
exerting
rysm itself. Compression was which the track was still open rysm unchanged.
of increasing
the patient,
subsein the affected
tenderness
and
a sudden enlargement of the sweffing and, of the pseudoaneurysm, immediately manually compressed the femoral artery to stop the bleeding. Emergency surgery was performed and revealed 2,000 mL of fresh blood surrounding the ruptured pseudoaneurysm. The small defect in the arterial wall was sutured and the hematoma The
patient
recovered
without
lions. We cannot
prove
that the
rupture
this
caused
by our
UGCR
case
was
sible that, uting
factor.
further
complica-
of the pseudoaneurysm
in
attempt.
However, it is poscoughing, it was a contrib-
together with the forceful Therefore, we stress that the following
basic pre-
cautions should be taken by anyone attempting UGCR: (a) a vascular surgeon should be aware of the timing of the procedure and be available on short notice, (b) an adequate intravenous line should be established before UGCR, and (c) at least one other person other than the operator should be present to
assist
in case of emergency.
dures.
References References
1.
1.
Rasmussen F, Lindequist 5, Larsen C,Justesen P. Therapeutic effed of hysterosalpingography: oil- versus water-soluble contrast media: a randomized prospective study. Radiology 1991; 179:75-78.
2.
Lindequist S,Justesen ity and complications
soluble 1991;
contrast
P, Larsen
media:
C, Rasmussen
F.
of hysterosalpingography: a randomized prospective
Diagnostic
2.
qual-
oil- versus waterstudy. Radiology
3.
179:69-74.
Steen Lindequist, MD, Finn Rasmussen, MD, and Per Justesen, MD Department of Diagnostic Radiology, Hospital 5000 Odense C, Denmark
MD,
Claus
Odense
4.
Larsen,
Feilmeth BD, Buckner NK, Ferreira JA, et aL Postcatheterization femoral artery injuries: repair with color flow US guidance and C-clamp assistance. Radiology 1992; 182:570-572. Feilmeth BD, Roberts AC, Bookstein JJ, et aL Postangiographic femoral artery injuries: nonsurgical repair with US-guided cornpression. Radiology 1991; 178:671-675. Feilmeth BD, Baron SB, Brown PR, et al. Repair of postcatheterizalion femoral pseudoaneurysrns by color flow ultrasound guided compression. Am HeartJ Dorfman GS, Cronan JJ.
Rupture US-guided
of Pseudoaneurysm Compression Repair
ries: is there
Johan A. Dol, MD,* J A. Reekers, MD,* and Jan G. Kromhout, MD, PhDt Departments of Diagnostic Radiology* and Vascular Surgery,t Academic
Medical
Center
9, 1105 AZ Amsterdam,
The Netherlands
Editor:
We read with interest the recent artides by Feilmeth et al (1-3) about ultrasound (US)-guided compression repair (UGCR) of postcatheterization
femoral
artery
injuries.
We
have
been
eval-
lions by means tiously request
new
technique,
the
only
complication
in our
series
Color Doppler imaging ing from the common track.
There
pression 284
were
showed
#{149} Radiology
revealed a 3-cm pseudoaneurysm arisfemoral artery with a 10-mm-long flow no contraindications to UGCR. A trial cornthat the track could be dosed without dosing
Harvard
report documents the contribution of the radiolresolution of a medical problem. The quality and of the report often depend on knowing the
appropriateness clinical circumstances of the patient. Therefore, it is ironic that obtaining this relevant information is often so difficult. This may result in time-consuming phone inquiries and searches through the patient’s medical records or vague and nonspecific
with
was vasovagal collapse in one patient. Recently, however, we encountered a serious life-threatening event during UGCR. A 61-year old woman presented with a pulsatile mass in the right groin 24 hours after diagnostic cardiac catheterization. She was receiving fenprocoumon anticoagulation therapy.
and
Editor:
The radiology ogist toward
language
this
this
A Radiology Solution
MD, and Ferris M. Hall, MD of Radiology, Beth Israel Hospital Medical School, 330 Brookline Avenue, Boston, MA 02215
method (4). Our results in 21 patients with false aneurysms are promising: 18 (86%) were treated successfully with UGCR. Feilmeth et al (1-3) report two complications in a total of 53 patients: acute chest pain in one patient and arterial thrombosis in another. In almost 1 year of growing experience uating
Clinical Information: a Computer-based
From: Morris Simon, Department
Attempted
From:
Meibergdreef
femoral artery injuRadiology 1991; 178:
629-630.
University
during
123:547-551.
Postcatheterization a role for nonsurgical treatment?
N Obtaining Problem with
.
1992;
in the
efit of medical lem. Our
hospital
use, permits
or from
radiology
report.
computerization computer
the direct
We
describe
an
that can help system,
entry
like
of requests
benthis prob-
ancillary
solve
others currently in for radiologic examina-
many
of a computer network Physicians can expediclinical information from any hospital terminal
an office computer
connected
to the hospital
network
with a modem. This requisition system is used for most of our inpatients and many outpatients. When requesting clinical information by means of a computer, the dinician is prompted to
enter (a) medical background information for the present examination. if information aminations of the same patient is requested, ground
information
automatically
reappears
and (b) the reason follow-up exthe medical backand is usually left
from
October1992
to the
Editor
.
Potential Therapeutic Effect of Oil-soluble Contrast Media in Hysterosalpingography
with df=
From:
mussen
David
B. Spring
Oakland,
Kaiser
Permanente
Medical
Center
CA
Howard E. Barkan, DrPH Department of Nursing, Sonoma Sonoma,
State
University
April
1991
used.
Lindequist et al (1) and Rasthe pregnancy rates after hysterosalfour different contrast media (diatriioxaglate, and ethiodized poppy-
They
found
that
three
times
as many
patients became pregnant after HSG with oil-based contrast media than with water-based contrast media. If valid, these findings should guide our choice of contrast agents when evaluating infertile women for fallopian tube disorders. Several potential methodologic problems cause us to queslion the validity of their condusions (1,2). HSG findings are often used to guide the conduct of subsequent laparoscopy or other operative procedures. In some procedures, it may be necessary to introduce other materials through the fallopian tubes. Whether
other
procedures-either
laparoscopy
gery-were performed during women (regardless of whether dear from the artides (1,2). In addition,
This
the
statistic
was
(x2
significant
7.34,
=
the data presented by Lindequist et al (1) and Raset al (2), investigators in this country remain reluctant to advocate the use of oil-based contrast agents (4). We are organizing a multisite, nonexperimental, collaborative study to reexamine the therapeutic effect of all HSG contrast agents, including the sequence of multiple agents advocated by some (5), which also may encourage favorable outcomes in infertility others
with
this
common
interest
to
study.
of Radiology,
issue
et al (2) compared pingography (HSG) when zoate meglumine, iohexol, oil) were
agent.
.00676).
encourage join in our collaborative
mussen
seed
=
investigations. We wish to
CA
Editor: In the
oil-based
Despite
MD
of Radiology,
Department
an
1,P
authors
noted
or after HSG they became important
or open
lion Hospitals References 1. Lindequist ity
2.
3.
4. 5.
The medical
provided
editorial
S,Justesen
department
P, Larsen
C, Rasmussen
media:
of Kaiser
Founda-
a randomized
Diagnostic
F.
of hysterosalpingography:
complications
contrast
editing
assistance.
prospective
qual-
oil- versus waterstudy. Radiology
1991; 179:69-74. Rasmussen F, Lindequist 5, Larsen C,Justesen P. Therapeutic effed of hysterosalpingography: oil versus water-soluble contrast media-a randomized prospective study. Radiology 1991; 179:7578. Lee ET, Desu MM. A computer program for comparing K samples
with right-censored 321. Yoder IC, Hall DA. 157:675-683.
data. Comput
Programs
Hystemsalpingography
DeCherney
nancy
in the with
rate of diagnosis of underlying pathologic conditions HSG when oil- and water-soluble contrast media were used. Women examined with water-soluble contrast agents were almost twice as likely to have hydrosalpinx (diatrizoate, 22 of 104 patients; ioxaglate, 22 of 105 patients; iohexol, 26 of 105 patients) as were women examined with an oil-based agent (ethiozized poppy-seed oil, 13 of 103 patients). Bilateral hydrosalpinx almost always results in infertility if not treated. We adjusted the data from Figure 2 in the artide by Lindequist et al (1) to eliminate data concerning the potentially sterile women with bilateral or unilateral hydrosalpinx, and then reanalyzed the statistics. With both the x2 tabulation with the continuity correction and the survival statistic as described by Lee and Desu (3), we found even greater statistical differences in conception rates between women examined with conventional water-soluble contrast agents and women examined with ethiodized poppy-seed oil (x2 = 7.97, df = 1, P = .0048) and in term pregnancy rates of these women (x2 15.73, df = 1, P = .00007). The most important finding was the difference in term pregnancy rates of women examined with ethiodized poppy-seed oil and diatrizoate meglumine alone (x2 10.50, df = 1, P = .0014). Indeed, the driving force in the relative “therapeutic effect” suggested by Rasmussen et al (2) and Lindequist et al (1) appears to be the particularly low term pregnancy rates associated with use of the conventional agent diatrizoate meglumine. Of 315 women in whom no hydrosalpinx was found, 84 became pregnant. Women who did become pregnant were more than three times as likely to miscarry if they had been exammed with a water-based agent than if they had been examined
and
soluble
sur-
in any of the pregnant) is undifferences
ACknowledgment
1980;
AM, Kort H, Barney JB, DeVore oil-soluble hysterosalpingography 33:407-410.
rate with
Dr Lindequist
and colleagues
Biomed
1972; 2:315-
in the 1990s. AJR 1991; GR.
Increased pregdye. Fertil Steril
respond:
We appreciate Spring and Barkan’s interest in our artides cerning contrast media in HSG (1,2) and the opportunity respond to their comments.
conto
Several potential methodologic problems are stated, and the effects of laparoscopy or surgery performed after HSG on the pregnancy rates are suggested as one of the problems. Indeed, it would have been a real methodologic problem if a priori we
had changed the post-HSG procedure with regard to laparoscopy and/or surgery and, thus, introduced a bias that could have been an advantage or disadvantage for one or more of the contrast media groups. Only 12 of the patients who became pregnant in the 9-month follow-up period after HSG underwent laparoscopy or surgery 2 years after HSG. This does not explain the differences in post-HSG pregnancy rates. We found that 134 of our 398 patients with infertility zoate, n = 37; ioxaglate, n = 36; iohexol, n = 27; ethiodized poppy-seed oil, n = 34) underwent laparoscopy and/or gery in the 2-year follow-up period. This is in agreement
the finding that the prevalence duration of infertility, infertility
of all other
parameters
(diatrisurwith
(age,
status, temperature curve, the partner’s sperm quality, previous gynecologic diseases and surgery, and hormonal treatment before and after HSG) did not
show
statistically significant differences between the four congroups (1,2). We do not think that the calculations made by Drs Spring and Barkan alter the condusions of our study. The pregnancy trast
media
283
rate
after
with
HSG
diatrizoate
the estimated spontaneous the term pregnancy rate trizoate “driving
meglumine
associated
with
force”
meglumine is comparable pregnancy rate (1). It is true
was high
and
appears
low in the patients in those receiving
to be the high
oil. Conversely, the oil-based medium
the artery
receiving diaoil, but the
(term)
the high
to that
pregnancy
pregnancy
rate
rate
after
and without
About although
I minute warned
quently complained groin. We noticed suspecting rupture
design, and we have included one of the newest isomolar, nonionic dimer water-soluble contrast mediums, iotrolan. We hope to present the results of this new study at the 1992 RSNA scientific assembly. As indicated in our study of image quality (2), water-soluble contrast media were superior to oil-soluble contrast media in the depiction of the ampullary rugae; this may explain the different numbers of hydrosalpinx in the waterand oil-soluble groups. We agree that a bilateral hydrosalpinx, if untreated,
evacuated.
almost
always
results
lateral
hydrosalpinx
in infertility,
and that patients
can become
pregnant
after
with
HSG
a uni-
(1).
We look forward to seeing the results from the multicenter study organized by Spring and Barkan. We hope that it will be a randomized prospective trial with randomization in each center
to avoid
methodologic
the investigated
problems
population
such
and dinical
as differences
in
and radiologic
proce-
direct pressure on the aneuapplied for 20 minutes, after and the flow in the false aneu-
after compression was released, not to do so, coughed forcefully
could be a random phenomenon, although the statistics tell us that it probably is not. We are conducting further studies with the same prospective with
HSG
exerting
rysm itself. Compression was which the track was still open rysm unchanged.
of increasing
the patient,
subsein the affected
tenderness
and
a sudden enlargement of the sweffing and, of the pseudoaneurysm, immediately manually compressed the femoral artery to stop the bleeding. Emergency surgery was performed and revealed 2,000 mL of fresh blood surrounding the ruptured pseudoaneurysm. The small defect in the arterial wall was sutured and the hematoma The
patient
recovered
without
lions. We cannot
prove
that the
rupture
this
caused
by our
UGCR
case
was
sible that, uting
factor.
further
complica-
of the pseudoaneurysm
in
attempt.
However, it is poscoughing, it was a contrib-
together with the forceful Therefore, we stress that the following
basic pre-
cautions should be taken by anyone attempting UGCR: (a) a vascular surgeon should be aware of the timing of the procedure and be available on short notice, (b) an adequate intravenous line should be established before UGCR, and (c) at least one other person other than the operator should be present to
assist
in case of emergency.
dures.
References References
1.
1.
Rasmussen F, Lindequist 5, Larsen C,Justesen P. Therapeutic effed of hysterosalpingography: oil- versus water-soluble contrast media: a randomized prospective study. Radiology 1991; 179:75-78.
2.
Lindequist S,Justesen ity and complications
soluble 1991;
contrast
P, Larsen
media:
C, Rasmussen
F.
of hysterosalpingography: a randomized prospective
Diagnostic
2.
qual-
oil- versus waterstudy. Radiology
3.
179:69-74.
Steen Lindequist, MD, Finn Rasmussen, MD, and Per Justesen, MD Department of Diagnostic Radiology, Hospital 5000 Odense C, Denmark
MD,
Claus
Odense
4.
Larsen,
Feilmeth BD, Buckner NK, Ferreira JA, et aL Postcatheterization femoral artery injuries: repair with color flow US guidance and C-clamp assistance. Radiology 1992; 182:570-572. Feilmeth BD, Roberts AC, Bookstein JJ, et aL Postangiographic femoral artery injuries: nonsurgical repair with US-guided cornpression. Radiology 1991; 178:671-675. Feilmeth BD, Baron SB, Brown PR, et al. Repair of postcatheterizalion femoral pseudoaneurysrns by color flow ultrasound guided compression. Am HeartJ Dorfman GS, Cronan JJ.
Rupture US-guided
of Pseudoaneurysm Compression Repair
ries: is there
Johan A. Dol, MD,* J A. Reekers, MD,* and Jan G. Kromhout, MD, PhDt Departments of Diagnostic Radiology* and Vascular Surgery,t Academic
Medical
Center
9, 1105 AZ Amsterdam,
The Netherlands
Editor:
We read with interest the recent artides by Feilmeth et al (1-3) about ultrasound (US)-guided compression repair (UGCR) of postcatheterization
femoral
artery
injuries.
We
have
been
eval-
lions by means tiously request
new
technique,
the
only
complication
in our
series
Color Doppler imaging ing from the common track.
There
pression 284
were
showed
#{149} Radiology
revealed a 3-cm pseudoaneurysm arisfemoral artery with a 10-mm-long flow no contraindications to UGCR. A trial cornthat the track could be dosed without dosing
Harvard
report documents the contribution of the radiolresolution of a medical problem. The quality and of the report often depend on knowing the
appropriateness clinical circumstances of the patient. Therefore, it is ironic that obtaining this relevant information is often so difficult. This may result in time-consuming phone inquiries and searches through the patient’s medical records or vague and nonspecific
with
was vasovagal collapse in one patient. Recently, however, we encountered a serious life-threatening event during UGCR. A 61-year old woman presented with a pulsatile mass in the right groin 24 hours after diagnostic cardiac catheterization. She was receiving fenprocoumon anticoagulation therapy.
and
Editor:
The radiology ogist toward
language
this
this
A Radiology Solution
MD, and Ferris M. Hall, MD of Radiology, Beth Israel Hospital Medical School, 330 Brookline Avenue, Boston, MA 02215
method (4). Our results in 21 patients with false aneurysms are promising: 18 (86%) were treated successfully with UGCR. Feilmeth et al (1-3) report two complications in a total of 53 patients: acute chest pain in one patient and arterial thrombosis in another. In almost 1 year of growing experience uating
Clinical Information: a Computer-based
From: Morris Simon, Department
Attempted
From:
Meibergdreef
femoral artery injuRadiology 1991; 178:
629-630.
University
during
123:547-551.
Postcatheterization a role for nonsurgical treatment?
N Obtaining Problem with
.
1992;
in the
efit of medical lem. Our
hospital
use, permits
or from
radiology
report.
computerization computer
the direct
We
describe
an
that can help system,
entry
like
of requests
benthis prob-
ancillary
solve
others currently in for radiologic examina-
many
of a computer network Physicians can expediclinical information from any hospital terminal
an office computer
connected
to the hospital
network
with a modem. This requisition system is used for most of our inpatients and many outpatients. When requesting clinical information by means of a computer, the dinician is prompted to
enter (a) medical background information for the present examination. if information aminations of the same patient is requested, ground
information
automatically
reappears
and (b) the reason follow-up exthe medical backand is usually left
from
October1992
