Why Online Support Groups can be Good for Your Health
By Alicia Armeli

OnlineSupprtGroups

From apps that track your meals, sleep patterns, and heart rate to instantly accessing online medical records—the Internet actively takes care of its users.

And according to recent studies, logging on can do something even more priceless—like provide individuals with a sense of belonging that may reduce stress, improve mood, and increase quality of life.

The number of people searching the Internet for health information is on the rise. Pew Internet Project Surveys reported that eight out of ten users search online for health information, making it the third most popular online activity.1

Among the millions of websites that users have to choose from, a particular type of social media has surfaced as a popular resource for health information—online support groups.

Online support groups may be formed by nonprofit organizations, health clinics, advocacy groups, or even by a person affected by a specific health condition.2 And they serve the same purpose as those offline—bringing together individuals who have similar health interests and concerns.

But why join an online support group?

Online support group popularity has grown for many reasons—one of which stems from comfort and convenience. Chat rooms and message boards don’t have time or location restrictions.3 This can be useful for people who are homebound because information, advice, and support are made accessible in the privacy of their own homes.

What’s more, studies have found that once shielded by the invisibility of a computer screen, people find it easier to discuss topics they may consider otherwise embarrassing. This silent but strong support involves little to no emotional vulnerability.3

But far beyond comfort and anonymity, research shows that people participate in online support groups for another powerful reason—to offer their support to others.3

Online support groups may be a significant resource to people who face rare medical issues—especially those of which society may minimize. When people are connecting because they have something in common, it can help to normalize what’s happening and simultaneously offer empathy.4

And it’s this empathy and support that recent studies reveal may be the root of several health benefits.

When just diagnosed with an illness or living daily with symptoms, many can experience psychological, social and physical distress. Online support groups can help people cope with these stressors by improving mood and decreasing stress, thus speeding up recovery and increasing quality of life.3 5

“Certain studies have found that expressions of empathy, support, and personal narrative are some of the most common types of communication content in online support groups,” wrote Heidi Hammond, author of the article Social Interest, Empathy, and Online Support Groups4 published earlier this year in the Journal of Individual Psychology. It was found that “more active participation in an online support group was related to a reduction in distress later on.”

And this finding holds true in the world of fibroid support. Social networks like Facebook6 are full of private online support groups that offer a space for women to ask questions, read informational articles, share their stories, and receive words of encouragement from thousands of women who can relate to what they’re going through.

In reference to a Facebook fibroid support group, one woman wrote, “I just love this group. The support, motivation, encouragement, knowledge and laughs it gives us all.”

Another post welcomed new members, “You have come to the right place. These girls are like my family! So supportive and a wealth of knowledge…this group has kept me sane!”

Online support groups have much to offer individuals, but this virtual interaction should never take the place of in-person medical intervention. Each woman is unique and in order to receive tailored fibroid treatment, open communication must occur between every woman and her physician.

 

ABOUT THE AUTHOR   Alicia Armeli is a Freelance Writer and Photographer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

 

REFERENCES

  1. Pew Research Center. (2011). Health Information is a Popular Pursuit Online. Retrieved December 10, 2015, from http://www.pewinternet.org/2011/02/01/health-information-is-a-popular-pursuit-online/#fn-341-1
  2. Mayo Clinic. (2015). Support Groups: Make Connections, Get Help. Retrieved December 10, 2015 from http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/support-groups/art-20044655?pg=1
  3. Chung, J. E. (2014). Social networking in online support groups for health: how online social networking benefits patients. Journal of Health Communication, 19: 639–659. doi: 10.1080/10810730.2012.757396
  4. Hammond, H. (2015). Social interest, empathy, and online support groups. The Journal of Individual Psychology, 71(2): 174-184. doi: 10.1353/jip.2015.0008
  5. Sundar, S. S. (2015). The handbook of the psychology of communication technology. West Sussex, UK: John Wiley & Sons, Inc.
  6. Facebook. (2015). Retrieved December 14, 2015, from https://www.facebook.com/
Fibroids May Put Women at Risk for Anemia
By Alicia Armeli

anemia

Uterine fibroids are a common gynecological condition affecting 20 to 80 percent of women by age 50.1  Of the symptoms associated with fibroids, heavy menstrual bleeding can be one of the most troublesome.

And although considered inconvenient to say the least, heavy bleeding could unknowingly put a woman at danger for much more—like iron deficiency anemia and other related health problems.

According to the American College of Obstetricians and Gynecologists, abnormal uterine bleeding can be described as bleeding that occurs between periods, after sex, beyond menopause, and that can be characterized as heavier or longer than normal.2 Menstrual cycles that are longer than 35 days or shorter than 21 days are considered abnormal.

Although there are several reasons for abnormal bleeding, fibroids and their location within the uterus are important factors to consider. Submucosal fibroids, those that grow within the uterine cavity, may upset normal bleeding by pushing against the uterine lining and vessels supplying blood to the uterus.3,4  Intramural fibroids grow in the uterine wall and can change the shape of the uterine cavity, creating a bigger surface area and more lining to shed each month.  What’s more, intramural fibroids can limit the uterus’ ability to contract. Without normal contractions, blood flow to the uterine lining may be compromised and result in heavier than normal bleeding.3

Excessive blood loss during periods can have dangerous consequences like anemia—a serious health condition in which there aren’t enough red blood cells to carry oxygen to your tissues. Anemia-related complications include weakness, dizziness, fatigue, heart failure, and stroke.5,6

A study by Nelson and Ritchie published earlier this year in the American Journal of Obstetrics and Gynecology looked at 149 women treated at Harbor-UCLA Medical Center between 2008 and 2013 with low hemoglobin levels below 5 g/dL (normal range is 12.1 – 15.1 g/dL) attributed to heavy menstrual bleeding.7 Over 90 percent of the women reported heavy bleeding to be a common occurrence with two-thirds admitting not seeking medical help—even though they bled excessively for more than 6 months.

As a result, nearly 25 percent were producing high levels of platelets—a serious condition that could lead to abnormal blood clotting8 and an increased risk of heart attack, stroke, and other complications. The authors of the study found almost 50 percent of cases were due to uterine fibroids and a staggering near 30 percent were discharged without any instruction to prevent future bleeding.

“Even when faced with potentially life-threatening anemia because of chronic, excessive menstrual blood loss, some women are not impressed with the serious nature of their problem,” Nelson and Ritchie concluded. “Chronic excessive blood loss should be treated as both an urgent and potentially recurrent problem; physicians should address this clinical concern proactively.”

 

REFERENCES

  1. Office on Women’s Health: US Department of Health and Human Services. (2015). Uterine Fibroid Fact Sheet. Retrieved November 10, 2015, from https://www.womenshealth.gov/publications/our-publications/fact-sheet/uterine-fibroids.html
  2. The American College of Obstetricians and Gynecologists. (2012). Frequently Asked Questions: Gynecologic Problems. Retrieved November 10, 2015, from http://www.acog.org/-/media/For-Patients/faq095.pdf?dmc=1&ts=20151113T1143331924
  3. Page, L.R. (1997). Renewing Female Balance (4th ed.). Eden Prairie, MN: Healthy Healing Publications.
  4. Puri, K., Famuyide, A. O., Erwin, P. J., Stewart, E. A. Laughlin-Tommaso, S. K. (2014). Submucosal fibroids and the relations to heavy menstrual bleeding and anemia. American Journal of Obstetrics and Gynecology, 210(1): 38.e1-38.e7. doi: 10.1016/j.ajog.2013.09.038
  5. National Heart, Lung, and Blood Institute, US Department of Health & Human Services. (2012). What Are the Signs and Symptoms of Anemia? Retrieved October 14, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/anemia/signs
  6. Naito, H., Naka, H., Kanaya, Y., Yamazaki, Y., & Tokinobu, H. (2014). Two cases of acute ischemic stroke associated with iron deficiency anemia due to bleeding from uterine fibroids in middle-aged women. Internal Medicine, 53: 2533-2537. doi: 10.2169/internalmedicine.53.262
  7. Nelson, A. L., & Ritchie, J. J. (2015). Severe anemia from heavy menstrual bleeding requires heightened attention. American Jouranal of Obstetrics and Gynecology, 213(1): 97.e1-97.e6. doi:http://dx.doi.org/10.1016/j.ajog.2015.04.023
  8. Cleveland Clinic. (2011). Hypercoagulable States (Blood Clotting Disorders). Retrieved November 12, 2015, from https://my.clevelandclinic.org/services/heart/disorders/hypercoagstate
Doctor, How Much Is This Going to Hurt? Debunking UFE’s Pain Myths
By Alicia Armeli

UFE_Pain

Even though uterine fibroid embolization (UFE) has the data to support its safety and efficacy, it still faces a major hurdle when it comes to gaining public acceptance.

“The major misconceptions with UFE are that it’s a painful procedure that requires general anesthesia or a hospital stay,” explains Dr. Michael J. Hallisey, MD, Chief Interventional Radiologist at Hartford Hospital in Hartford, Connecticut.  “UFE is now an outpatient procedure that can be performed with simple intravenous sedation.”

So where does this misunderstanding come from?

To answer this question, it’s important to first understand the basics of UFE. During UFE, tiny particles are injected into the uterine arteries to cut off blood supply to the fibroids. This causes them to shrink—thereby diminishing the severity of symptoms.

But UFE’s very reason for success is also believed to be the primary source of any pain associated with the procedure. When blood to the fibroids is restricted, this then causes a cascade of events.

“The pain occurs because the fibroids are starved of their blood supply,” describes Dr. Hallisey. “The cells of the fibroids rupture and expand in the uterus and so the initial phase feels like significant menstrual cramps.”

This cramping is part of what’s referred to as post-embolization syndrome (PES). Cramps following the procedure seem to worsen within the first 2 to 3 hours, reaching a constant intensity for 8 to 12 hours, and then subside significantly. Along with pelvic pain, other common symptoms of PES can include nausea, vomiting, and fatigue.1 Dr. Hallisey adds that neither fibroid size nor location seem to affect the level of discomfort experienced.

That being said, is UFE simply a matter of no pain, no gain? Not exactly.

But the trick to controlling pain happens well before the procedure.

“In the past, many interventional radiologists were giving pain medication at the start and that medication will just be getting absorbed at the time they’re performing the procedure,” says Dr. Hallisey. “It makes more sense to give pre-procedural medication, so they don’t feel the pain during the procedure.”

Although pain protocols differ between medical facilities, Dr. Hallisey administers a cocktail of pain medications before the procedure to ensure his patients remain comfortable. Both a fentanyl patch is applied to the skin and oral OxyContin is administered.

This method, he explains, makes it so the medications are already absorbed into the bloodstream before the procedure. It also helps to ensure patients won’t need intravenous narcotics afterwards, but instead can take oral over the counter pain medication—like Aleve®—when they go home. “As an outpatient procedure, 50 percent of patients are off their pain medication 24 hours after the procedure and another 50 percent in 48 hours.”

And the literature agrees. Seminars in Interventional Radiology wrote, “By administering longer-acting medications before the patient begins to experience pain, the dose required to control the pain is less. A lower dose of narcotics may decrease the level of nausea many patients experience as well.”1

As mentioned, narcotics are commonly the drugs of choice to ease pain, but at the same time they can cause nausea and vomiting.2 This can decrease the overall effectiveness of any pain medication taken.

“The biggest problem that patients complain about is that they aren’t absorbing their medications because they get nauseous,” says Dr. Hallisey. “Because of this, we give them a medication called Reglan to get their intestines moving and to better absorb the pain medication.” Additionally, giving anti-nausea medication before the procedure seems to be a proactive and beneficial step.1

But aside from medication, what else can women do to help their recovery?

“One of the best things women can do is hydrate themselves 24 hours before the procedure,” encourages Dr. Hallisey. “Hydration helps with recovering quicker. A heating pad on the abdomen can help afterwards.”

And to take it a step further, Dr. Hallisey believes the success of a procedure, and subsequent recovery, starts with open dialogue during the initial consultation.

“Women need to ask their doctors if they give pre-procedural pain medication and if they perform UFE entirely as an outpatient procedure,” advises Dr. Hallisey. “If a woman goes to a doctor who doesn’t offer this, then she needs to call around and find one who does. UFE isn’t that painful of a procedure and it works very well.”

 

ABOUT THE AUTHOR  Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR  Michael J. Hallisey is Chief Interventional Radiologist at Hartford Hospital in Hartford, Connecticut. Board certified in Vascular and Interventional Radiology, Dr. Hallisey specializes in several areas of medicine including uterine fibroid embolization, balloon angioplasty, and cancer chemoembolization, to name a few. He’s one of Castle Connolly America’s Top Doctors and was the recipient of the Compassionate Doctor Recognition award.

REFERENCES

  1. Spencer, E. B., Stratil, P., & Mizones, H. (2013). Clinical and periprocedural pain management for uterine artery embolization. Seminars in Interventional Radiology, 30(4): 354-363. doi: 10.1055/s-0033-1359729
  2. Smith, H. S., Smith, J. M., & Seidner, P. (2012). Opioid-induced nausea and vomiting.  Annals of Palliative Medicine, 1(2). doi: 10.3978/j.issn.2224-5820.2012.07.08
Are Fibroids the Cause of Perimenopausal Heavy Flow?
By Alicia Armeli

Heavy and irregular periods are common among perimenopausal women. And uterine fibroids are often blamed as the culprit. But as experts and literature suggest, the cause of abnormal bleeding could be something else entirely.

According to the Journal of Steroid Biochemistry and Molecular Biology, a woman could be considered perimenopausal if, at a certain age—usually 45 years and older, she experiences menopausal-like symptoms such as hot flushes, achy joints, difficulty sleeping, night sweats, and changes to her menstrual cycle.1 For some perimenopausal women, periods can vary between 14 and 50 days. Along with being irregular, these periods can be abnormally heavy.

Uterine fibroids also seem to be prevalent during this stage of life. But are they solely responsible for heavy bleeding as some may think?

“Perimenopausal heavy flow is so common that it could almost be called normal. But there’s a physical reason why fibroids causing this bleeding doesn’t make sense,” says Dr. Jerilynn C. Prior Professor of Medicine and Endocrinology at the University of British Columbia and the Founder of the Center for Menstrual Cycle and Ovulation Research. “Fibroids grow within the muscle of the uterine wall and most of the time they’re far from the lining of the uterus—or the endometrium—which is what bleeds.”

Only one type of fibroid, submucosal, grows just under the uterine lining and can be responsible for the most dramatic and noticeable symptoms like heavy prolonged bleeding. But less than 10 percent of fibroids are submucosal.2

A landmark study published in the Journal of American Medical Women’s Association found similar and supportive data.3  Seltzer and colleagues looked at the medical charts of 500 perimenopausal women. Of those, 91 were found to have heavy, prolonged, and irregular periods. But a closer look found that only six of the 91 women actually had uterine fibroids.

“Fibroids and heavy bleeding can co-occur at this time because of the hormonal changes of perimenopause,” explains Dr. Prior. “Namely higher estrogen and lower progesterone cause both heavy bleeding and fibroids to grow. During perimenopause, estrogen is on average 30% higher and progesterone is 50% lower. This amount of progesterone is not adequate for the amount of estrogen.”

Estrogen runs high during perimenopause because the body wants to rid itself of all potential ovarian follicles in preparation for menopause. And every follicle makes estrogen. With each cycle, more follicles are recruited, dissolved, and the result is higher estrogen. “Estrogen is what makes tissues grow,” continues Dr. Prior. “It makes the muscle cells of fibroids grow and it makes the lining of the uterus thicken. But you need progesterone to counterbalance estrogen’s action and to make the endometrium secretory and more mature.”

Knowing this, what’s the first step a perimenopausal woman can take to tame her period?

Before tackling any hormonal imbalance, Dr. Prior offers an even simpler solution that can be used at any age for heavy periods: Ordinary over the counter ibuprofen.

“There’s a balance of prostaglandins—a fatty hormone—in the uterus,” says Dr. Prior. “And if these two prostaglandins are out of balance, that is part of causing heavy flow.” Ibuprofen is a drug that can alter this imbalance.2 “Taking 200-400 milligrams of ibuprofen with each meal—breakfast, lunch, and dinner—on every heavy flow day decreases flow by a quarter to a half. Every woman everywhere should know that.”

If a woman is still bleeding heavily and chooses hormone therapy, Dr. Prior prescribes progesterone, which shouldn’t be confused with progestin—a synthetic form of progesterone that has been linked to breast cancer.4 Length of time taking progesterone along with prescribed amounts will vary amongst women, but this regimen does show promise.

Along with alleviating heavy bleeding, “progesterone usually improves sleep and decreases anxiety and stress responses,” adds Dr. Prior. But, she admits, progesterone can be expensive.

There’s also concern in the medical community that taking progesterone may upset the hormonal balance in women with regularly occurring periods and could result in worsening fibroids. This is a broad generalization Dr. Prior wants to clarify.

“The assumption is if you have a regular period you are making progesterone as well as estrogen—this isn’t correct,” Dr. Prior argues. Earlier this year, Dr. Prior and colleagues published a study that examined progesterone levels in over 3000 women, average age of 41 years, with clinically normal menstrual cycles.5

“One-third did not have a high enough progesterone level—in other words, did not have a high enough level to say they ovulated. You can have perfectly regular cycles and not ovulate” and, therefore, not be making adequate progesterone. Since every woman’s hormone levels differ, progesterone therapy may be a viable option to control perimenopausal heavy bleeding while not adversely affecting fibroids.

At any age, heavy menstrual bleeding takes a great toll on a woman’s life, but it doesn’t have to. Understanding the cause and receiving appropriate treatment can provide necessary relief.

 

ABOUT THE AUTHOR   Alicia Armeli is a Freelance Writer and Photographer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR  Jerilynn C. Prior is a Professor of Medicine and Endocrinology at the University of British Columbia and the Founder of the Center for Menstrual Cycle and Ovulation Research (CeMCOR). By publishing several research papers that examine the effects of women’s hormone levels through the changing life cycles as well as public speaking, Dr. Prior continuously works with the goal of educating the public about important topics surrounding women’s health. Dr. Prior is author of the award-winning book, Estrogen’s Storm Season: Stories of Perimenopause and co-author of the book, Why Progesterone Is Better for Women’s Health. 

REFERENCES

  1. Hale, G. E., Robertson, D. M., & Burger, H. G. (2014). The perimenopausal woman: endocrinology and management. Journal of Steroid Biochemistry and Molecular Biology, 142(2014): 121-131.
  2. The Centre for Menstrual Cycle and Ovulation Research. (2014). For Healthcare Providers: Managing Menorrhagia Without Surgery. Retrieved November 3, 2015, from http://www.cemcor.ca/resources/healthcare-providers-managing-menorrhagia-without-surgery
  3. Seltzer, V. L., Benjamin, F., & Deutsch, S. (1990). Perimenopausal bleeding patterns and pathologic findings. Journal of the American Medical Women’s Association, 45(4): 132-134.
  4. Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. The Journal of the American Medical Association, 288(3): 321-333. doi: 10.1001/jama.288.3.321.
  5. Prior, J. C., Naess, M., Langhammer, A., & Forsmo, S. (2015). Ovulation prevalence in women with spontaneous normal-length menstrual cycles—a population-based cohort from HUNT3, Norway. PLOS ONE. doi: 10.1371/journal.pone.0134473
Learn More about Treating Fibroids from the Wrist

Dr. Aaron M. Fischman

Some interventional radiologists, including Dr. Aaron M. Fischman at Mount Sinai Medical Center in New York, are treating a woman’s fibroids from her wrist instead of the groin. Researchers have found this access point, referred to as transradial approach, to be less painful and less traumatic for women, allowing them to immediately sit up and move after uterine fibroid embolization (UFE)—with no overnight stay.

“Improving patient care and providing advanced treatment options are always on the minds of interventional radiologists. And this could be a game changer for image-guided minimally invasive treatments,” said Dr. Fischman.

For women wanting to learn more about this innovative treatment option, Dr. Fischman and The Fibroids Project are hosting a free teleconference on Tuesday, Dec. 8. Register now to be a part of this unique opportunity to learn more about UFE through the wrist and ask Dr. Fischman your questions.

After Decades, UFE Is Still Found to Be Safe and Effective
By Alicia Armeli

Hippocrates referred to them as “uterine stones.” In medieval times, women who had them were said to possess evil spirits.1 And despite the fact that uterine fibroids are nothing more than noncancerous tumors of the womb—historically, they’ve been misunderstood. But fortunately, advancements in medicine have increased the knowledge surrounding this condition as well as the number of treatment options available to women.

Gone are the days when surgery was the only choice of therapy. Now, minimally invasive procedures, like uterine fibroid embolization (UFE), provide women with an option that alleviates symptomatic fibroids—all while avoiding both major surgery and a long recovery.

The procedure itself is performed by an interventional radiologist and takes approximately one hour. A small incision is made in the thigh and a thin catheter is threaded through the femoral artery and then into the uterine arteries that feed blood to the fibroids. Tiny microspheres called embolics are injected into the uterine arteries, blocking blood flow to the fibroids, causing them to shrink. By doing so, UFE can ease abnormal bleeding and pressure symptoms along with preventing further growth—even in women with large fibroids.

Although considered a newer approach, UFE has been used for decades as a means of controlling heavy bleeding after giving birth.2 UFE’s first success in treating actual fibroids dates back to 1974. A Parisian neuroradiologist, Dr. Jean-Jacques Merland, was the first to treat a woman who suffered from severe menstrual bleeding due to fibroids.3

Following this achievement, Dr. Merland teamed up with gynecologist, Dr. Jacques Ravina. Together, they used UFE to reduce blood loss during the surgical removal of fibroids—a procedure called myomectomy. Nearly two decades later in 1993, Dr. Merland and Dr. Ravina opened a center that allowed them to study the safety and effectiveness of UFE. Their initial studies showed UFE to completely resolve symptoms in almost 70 percent of patients.3

Today, UFE’s success continues to be on the rise with current statistics showing a 90 percent cure rate.4 And even though UFE’s trusted procedure technique has essentially stayed the same for over 40 years, physicians and researchers are constantly striving to improve every woman’s experience.

By reexamining each step of the procedure, significant facets of UFE such as new and more effective pain management protocols are emerging and superior embolics5 are being discovered—all with the goal of bettering patient care.

 

ABOUT THE AUTHOR   Alicia Armeli is a Freelance Writer and Photographer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

REFERENCES

  1. Bozini, N., & Baracat, E. C. (2007). The history of myomectomy at the Medical School of University of Sao Paulo. Clinics, 62(3). http://dx.doi.org/10.1590/S1807-59322007000300002
  2. Uterine Fibroids: Treating fibroids non-invasively. (2015). Uterine Artery Embolization (UAE). Retrieved October 30, 2015, from http://www.uterine-fibroids.org/uae.html
  3. Gonsalves, C. (2008). Uterine artery embolization for treatment of symptomatic fibroids. Seminars in Interventional Radiology, 25(4): 369-377. doi: 10.1055/s-0028-1103001
  4. McLucas, B., Voorhees Iii, W. D., & Elliott, S. (2015). Fertility after uterine artery embolization: a review. Minimally Invasive Therapy & Allied Technologies, 2: 1-7.
  5. Das, R., Champaneria, R., Daniels, J. P., & Belli, A. M. (2014). Comparison of embolic agents used in uterine artery embolisation: a systematic review and meta-analysis. Cardiovascular and Interventional Radiology, 37(5): 1179-90. doi: 10.1007/s00270-013-0790-0