Percutaneous Large-Bore Pulmonary Thrombectomy with the FlowTriever Device: Initial Experience in Intermediate-High and High-Risk Patients

OBJECTIVES

This retrospective cohort study investigates outcomes of patients with intermediate-high and high-risk pulmonary embolism (PE) who were treated with transfemoral mechanical thrombectomy (MT) using the large-bore Inari FlowTriever aspiration catheter system.

MATERIAL AND METHODS

Twenty-seven patients (mean age 56.1 ± 15.3 years) treated with MT for PE between 04/2021 and 11/2021 were reviewed. Risk stratification was performed according to European Society of Cardiology (ESC) guidelines. Clinical and hemodynamic characteristics before and after the procedure were compared with the paired Student's t test, and duration of hospital stay was analyzed with the Kaplan-Meier estimator. Procedure-related adverse advents were assessed.

RESULTS

Of 27 patients treated, 18 were classified as high risk. Mean right-to-left ventricular ratio on baseline CT was 1.7 ± 0.6. After MT, a statistically significant reduction in mean pulmonary artery pressures from 35.9 ± 9.6 to 26.1 ± 9.0 mmHg (p = 0.002) and heart rates from 109.4 ± 22.5 to 82.8 ± 13.8 beats per minute (p < 0.001) was achieved. Two patients died of prolonged cardiogenic shock. Three patients died of post-interventional complications of which a paradoxical embolism can be considered related to MT. One patient needed short cardiopulmonary resuscitation during the procedure due to clot displacement. Patients with PE as primary driver of clinical instability had a median intensive care unit (ICU) stay of 2 days (0.5-3.5 days). Patients who developed PE as a complication of an underlying medical condition spent 11 days (9.5-12.5 days) in the ICU.

CONCLUSION

In this small study population of predominantly high-risk PE patients, large-bore MT without adjunctive thrombolysis was feasible with an acceptable procedure-related complication rate.

Hepatocellular carcinoma tumor thrombus entering the right atrium treated with combining percutaneous and intravenous high-dose-rate brachytherapy: a case report

The presented report describes a case of a Hepatocellular carcinoma (HCC) tumor thrombus (TT) infiltrating the inferior vena cava (IVC) and the right atrium (RA) in a 66-year old male patient who initially presented with TT related symptoms. CT-guided high-dose-rate brachytherapy (HDRBT) was performed for both, the intraparenchymal primary and the TT. A marked improvement of the tumor-related symptoms and shrinkage of the tumor mass were achieved six months after treatment initiation. The combination of intravascular and percutaneous HDRBT demonstrating a promising approach to palliate tumor-related symptoms in advanced HCC with macrovascular invasion.

Central Venous Port Catheters: Evaluation of Patients' Satisfaction with Implantation under Local Anesthesia

Purpose

Evaluation of pain perception and patient satisfaction after implantation of a central venous port catheter system under local anesthesia.

Methods

A total of 100 consecutive patients (25 outpatients, 75 inpatients) who underwent successful implantation of a port catheter into the internal jugular vein from May through August 2007 were given an 8-item questionnaire. The extent of information about the implantation, the pain perception during implantation and the friendliness of the physician and nurse were evaluated. Furthermore, the patients were asked to assess their degree of anxiety and the pain they experienced during the intervention and to give an appraisal of whether local anesthesia was adequate. Each question was assessed on a 10–point scale (10 = very true to 1 = not at all true). In addition, the overall duration of the intervention (including patient preparation, implantation, patient aftercare, disinfection of the room) was documented.

Results

Patients felt highly satisfied with the way they were informed (mean score of 9.65) and considered the treating physician (9.89) and nurse (9.9) extremely friendly. Local anesthesia was rated as nearly completely adequate (9.56) and the degree of pain experienced was low (9.05; 10 = no pain). The average anxiety score was 8.56 (10 = not afraid at all). Overall satisfaction with the treatment was very high (9.62; outpatients: 9.72) and patients would recommend port catheter implantation at our department to others (9.77). The mean overall duration of the intervention was 76 min (range 40–120 min).

Conclusion

Positive patient reactions indicate that radiologic port catheter implantation under local anesthesia is a minimally invasive intervention with high patient satisfaction that can be performed on an outpatient basis and is a valid alternative to surgical implantation.

Irreversible Electroporation in Interventional Oncology: Where We Stand and Where We Go

Irreversible electroporation (IRE) is the latest in the series of image-guided locoregional tumor ablation therapies. IRE is performed in a nearly non-thermal fashion that circumvents the "heat sink effect" and allows for IRE application in proximity to critical structures such as bile ducts or neurovascular bundles, where other techniques are unsuitable. IRE appears generally feasible and initial reported results for tumor ablation in the liver, pancreas and prostate are promising. Additionally, IRE demonstrates a favorable safety profile. However, site-specific complications include bile leaking or vein thrombosis and may be more severe after pancreatic IRE compared to liver or prostate ablation. There is limited clinical evidence in support of the use of IRE in the kidney. In contrast, pulmonary IRE has so far failed to demonstrate efficacy due to practicability limitations. Hence, this review will provide a state-of-the-art update on available clinical evidence of IRE regarding feasibility, safety and oncologic efficacy. The future role of IRE in the minimally invasive treatment of solid tumors will be discussed.

KEY POINTS

• Preclinical findings of IRE have been successfully translated into clinical settings.• Non-thermal ablation is able to prevent the "heat sink effect" and collateral damage.• IRE should primarily be applied to tumors adjacent to sensitive structures (e. g. bile ducts).IRE efficacy appears promising in the liver, pancreas and prostate with tolerable morbidity.• In contrast, there are no evidential benefits of IRE in the lung parenchyma. Citation Format: • Savic LJ, Chapiro J, Hamm B et al. Irreversible Electroporation in Interventional Oncology: Where We Stand and Where We Go. Fortschr Röntgenstr 2016; 188: 735 - 745.

Activity-based cost analysis of hepatic tumor ablation using CT-guided high-dose rate brachytherapy or CT-guided radiofrequency ablation in hepatocellular carcinoma

Purpose

To analyse and compare the costs of hepatic tumor ablation with computed tomography (CT)-guided high-dose rate brachytherapy (CT-HDRBT) and CT-guided radiofrequency ablation (CT-RFA) as two alternative minimally invasive treatment options of hepatocellular carcinoma (HCC).

Materials and methods

An activity based process model was created determining working steps and required staff of CT-RFA and CT-HDRBT. Prorated costs of equipment use (purchase, depreciation, and maintenance), costs of staff, and expenditure for disposables were identified in a sample of 20 patients (10 treated by CT-RFA and 10 by CT-HDRBT) and compared. A sensitivity and break even analysis was performed to analyse the dependence of costs on the number of patients treated annually with both methods.

Results

Costs of CT-RFA were nearly stable with mean overall costs of approximately 1909 €, 1847 €, 1816 € and 1801 € per patient when treating 25, 50, 100 or 200 patients annually, as the main factor influencing the costs of this procedure was the single-use RFA probe. Mean costs of CT-HDRBT decreased significantly per patient ablation with a rising number of patients treated annually, with prorated costs of 3442 €, 1962 €, 1222 € and 852 € when treating 25, 50, 100 or 200 patients, due to low costs of single-use disposables compared to high annual fix-costs which proportionally decreased per patient with a higher number of patients treated annually. A break-even between both methods was reached when treating at least 55 patients annually.

Conclusion

Although CT-HDRBT is a more complex procedure with more staff involved, it can be performed at lower costs per patient from the perspective of the medical provider when treating more than 55 patients compared to CT-RFA, mainly due to lower costs for disposables and a decreasing percentage of fixed costs with an increasing number of treatments.

Can early computed tomography angiography after endovascular aortic aneurysm repair predict the need for reintervention in patients with type II endoleak?

PURPOSE

This study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions.

METHODS

We retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR. On the basis of follow-up examinations (mean follow-up period 911 days; range, 373-1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention. CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesenteric artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome.

RESULTS

Univariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm(3); reintervention group: 3227.7 ± 2693.8 mm(3); cutoff value of 2,386 mm(3); p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p < 0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a "complex type" endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02).

CONCLUSIONS

Early CTA can predict the future need for reintervention in patients with type II endoleak. Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.

Unresectable colorectal liver metastases: percutaneous ablation using CT-guided high-dose-rate brachytherapy (CT-HDBRT)

PURPOSE

To evaluate the clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) of unresectable colorectal liver metastases (CRLMs).

MATERIALS AND METHODS

Retrospective analysis of all consecutive patients with unresectable CRLMs treated with CT-HDRBT between January 2008 and November 2012. Treatment was performed by CT-guided catheter placement and high-dose-rate brachytherapy with an iridium-192 source. MRI follow-up was performed after 6 weeks and then every 3 months post-intervention. The primary endpoint was local tumor control (LTC); secondary endpoints included time to progression (TTP) and overall survival (OS).

RESULTS

80 heavily pretreated patients with 179 metastases were available for MRI evaluation for a mean follow-up time of 16.9 months. The mean tumor diameter was 28.5 mm (range: 8 - 107 mm). No major complications were observed. A total of 23 (12.9 %) local tumor progressions were observed. Lesions ≥ 4 cm in diameter showed significantly more local progression than smaller lesions (< 4 cm). 50 patients (62.5 %) experienced systemic tumor progression. The median TTP was 6 months. 28 (43 %) patients died during the follow-up period. The median OS after ablation was 18 months.

CONCLUSION

CT-HDRBT is an effective technique for the treatment of unresectable CRLMs and warrants promising LTC rates compared to thermal ablative techniques. A combination with other local and systemic therapies should be evaluated in patients with lesions > 4 cm in diameter, in which higher progression rates are expected.

KEY POINTS

• CT-HDRBT enables a highly cytotoxic irradiation of colorectal liver metastases with simultaneous conservation of important neighboring structures (eg liver parenchyma, bile ducts and bowel)• The local tumor control rates obtained by CT-HDRBT in patients with colorectal liver metastases are promising, also compared to the local tumor control rates after RFA• Metastases with a diameter of 4 cm or abow, display a higher local progression rate after CT-HDRBT, therefor a combination therapy with other locoregional or systemic treatments should be investigated in prospective studies.

Radiofrequency ablation of osteoid osteomas: analgesia and patient satisfaction in long-term follow-up

PURPOSE

To review the long term clinical outcomes in the treatment of osteoid osteoma (OO) using radiofrequency ablation (RFA).

MATERIALS AND METHODS

Our retrospective study included 59 patients who were treated in the period from April 2001 to December 2012 due to a symptomatic OO using RFA. Here, the occurrence of complications and postoperative recurrence, as well as postoperative patient satisfaction were examined. Patients satisfaction was assessed by means of a telephone interview with the visual analogue scale (VAS).

RESULTS

Mean follow-up was 50 months (2 –116 months). The average size of the nidus was 6mm (range 2 – 14 mm). After initial radiofrequency ablation 11.8 % (7/59) of patient showed a recurrence of symptoms. Symptoms could successfully be treated by a second ablation in 5 patients. Assisted success rate was therefore 96.6 % (57/59). The complication rate was 5.1 % (2 major and one minor complication). Furthermore we report a very high patient satisfaction and acceptance of therapy.

CONCLUSION

RFA is a very successful therapy of symptomatic OOs with a high patient satisfaction.

KEY POINTS

Osteoid osteomas (OO) are rare benign bone tumors of the childhood and adolescence. Treatment of OOs with minimal-invasive radiofrequency ablation (RFA) shows a high patient satisfaction. RFA is by now the standard therapy of symptomatic OOs.

Radiofrequency ablation of osteoid osteomas: analgesia and patient satisfaction in long-term follow-up

PURPOSE

To review the long term clinical outcomes in the treatment of osteoid osteoma (OO) using radiofrequency ablation (RFA).

MATERIALS AND METHODS

Our retrospective study included 59 patients who were treated in the period from April 2001 to December 2012 due to a symptomatic OO using RFA. Here, the occurrence of complications and postoperative recurrence, as well as postoperative patient satisfaction were examined. Patients satisfaction was assessed by means of a telephone interview with the visual analogue scale (VAS).

RESULTS

Mean follow-up was 50 months (2 - 116 months). The average size of the nidus was 6 mm (range 2 - 14 mm). After initial radiofrequency ablation 11.8 % (7/59) of patient showed a recurrence of symptoms. Symptoms could successfully be treated by a second ablation in 5 patients. Assisted success rate was therefore 96.6 % (57/59). The complication rate was 5.1 % (2 major and one minor complication). Furthermore we report a very high patient satisfaction and acceptance of therapy.

CONCLUSION

RFA is a very successful therapy of symptomatic OOs with a high patient satisfaction.

KEY POINTS

▶ Osteoid osteomas (OO) are rare benign bone tumors of the childhood and adolescence. ▶ Treatment of OOs with minimal-invasive radiofrequency ablation (RFA) shows a high patient satisfaction. ▶ RFA is by now the standard therapy of symptomatic OOs.

Percutaneous ablation of lymph node metastases using CT-guided high-dose-rate brachytherapy

OBJECTIVE

To assess the technical feasibility, safety and clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) for achieving local tumour control (LTC) in isolated lymph node metastases.

METHODS

From January 2008 to December 2011, 10 patients (six males and four females) with isolated nodal metastases were treated with CT-HDRBT. Five lymph node metastases were para-aortic, three were at the liver hilum, one at the coeliac trunk and one was a left iliac nodal metastasis. The mean lesion diameter was 36.5 mm (range 12.0-67.0 mm). Patients were followed up by either contrast-enhanced CT or MRI 6 weeks and then every 3 months after the end of treatment. The primary end point was LTC. Secondary end points included primary technical effectiveness rate, adverse events and progression-free survival.

RESULTS

The first follow-up examination after 6 weeks revealed complete coverage of all nodal metastases treated. There was no peri-interventional mortality or major complications. The mean follow-up period was 13.2 months (range 4-20 months). 2 out of 10 patients (20%) showed local tumour progression 9 and 10 months after ablation. 5 out of 10 patients (50%) showed systemic tumour progression. The mean progression-free interval was 9.2 months (range 2-20 months).

CONCLUSION

CT-HDRBT is a safe and effective technique for minimally invasive ablation of nodal metastases.

ADVANCES IN KNOWLEDGE

CT-HDRBT of lymph node metastases is feasible and safe. CT-HDRBT might be a viable therapeutic alternative to obtain LTC in selected patients with isolated lymph node metastases.

Treatment of osteoid osteoma using CT-guided radiofrequency ablation versus MR-guided laser ablation: a cost comparison

OBJECTIVE

To compare the costs of CT-guided radiofrequency ablation (RFA) and MR-guided laser ablation (LA) for minimally invasive percutaneous treatment of osteoid osteoma.

MATERIALS AND METHODS

Between November 2005 and October 2011, 20 patients (14 males, 6 females, mean age 20.3±9.1 years) underwent CT-guided RFA and 24 patients (18 males, 6 females; mean age, 23.8±13.8 years) MR-guided LA (open 1.0 Tesla, Panorama HFO, Philips, Best, Netherlands) for osteoid osteoma diagnosed on the basis of clinical presentation and imaging findings. Prorated costs of equipment use (purchase, depreciation, and maintenance), staff costs, and expenditure for disposables were identified for CT-guided RFA and MR-guided LA procedures.

RESULTS

The average total costs per patient were EUR 1762 for CT-guided RFA and EUR 1417 for MR-guided LA. These were (RFA/LA) EUR 92/260 for equipment use, EUR 149/208 for staff, and EUR 870/300 for disposables.

CONCLUSION

MR-guided LA is less expensive than CT-guided RFA for minimally invasive percutaneous ablation of osteoid osteoma. The higher costs of RFA are primarily due to the higher price of the disposable RFA probes.

[Percutaneous CT-guided high-dose brachytherapy (CT-HDRBT) ablation of primary and metastatic lung tumors in nonsurgical candidates]

PURPOSE

To evaluate the safety and efficacy of CT-guided high-dose brachytherapy (CT-HDRBT) ablation of primary and metastatic lung tumors.

MATERIALS AND METHODS

Between November 2007 and May 2010, all consecutive patients with primary or metastatic lung tumors, unsuitable for surgery, were treated with CT-HDRBT. Imaging follow-up after treatment was performed with contrast-enhanced CT at 6 weeks, 3 months and every 6 months after the procedure. The endpoints of the study were local tumor control and time to progression. The Kaplan-Meier method was used to estimate survival functions and local tumor progression rates.

RESULTS

34 procedures were carried out on 33 lesions in 22 patients. The mean diameter of the tumors was 33.3 mm (SD = 20.4). The first contrast-enhanced CT showed that complete ablation was achieved in all lesions. The mean minimal tumor enclosing dose was 18.9 Gy (SD = 2). Three patients developed a pneumothorax after the procedure. The mean follow-up time was 13.7 (3 - 29) months. 2 of 32 lesions (6.25 %) developed a local tumor progression. 8 patients (36.3 %) developed a distant tumor progression. After 17.7 months, 13 patients were alive and 9 patients had died.

CONCLUSION

CT-HDRBT ablation is a safe and attractive treatment option for patients with lung malignancies and allows targeted destruction of tumor tissue with simultaneous preservation of important lung structures. Furthermore, CT-HDRBT is independent of the size of the lesion and its location within the lung parenchyma.

Feasibility of hepatic radiofrequency ablation in patients with bilioenteric anastomoses

BACKGROUND/AIMS

Radiofrequency ablation (RFA) in the liver is contraindicated in the presence of bilioenteric anastomoses, because it predisposes to occasionally devastating infectious complications. The purpose of this single-center experience is to demonstrate the technical feasibility of such procedures.

METHODOLOGY

Patients with bilioenteric anastomoses were offered ultrasound-guided RFA, if an interdisciplinary tumor board endorsed this decision, or an intraoperative opportunity to achieve a tumor-free situation emerged. All procedures were carried out under general anesthesia in a surgical operation theatre. RFA was performed percutaneously (n=3) and open surgically (n=3) with two different types of monopolar devices. All patients received antibiotic prophylaxis with various different agents.

RESULTS

Six patients with seven tumor nodules were treated. The average age of the patients was 59 +/- 7 years. Mean size of the tumors was 20 +/- 7 mm. Median follow up was 15 months. No infectious complication including intrahepatic abscess occurred. No local recurrence was detected.

CONCLUSIONS

The presented data indicates the feasibility of RFA in patients with bilioenteric anastomoses, and infectious problems, namely intrahepatic abscess formation, do not inevitably occur. The role of antimicrobial prophylaxis remains unclear. The importance of ensuring an unobstructed and uninhibited biliary flow distally in the bilioenteric track is stressed.

Irinotecan versus best supportive care (BSC) as second-line therapy in gastric cancer: A randomized phase III study of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

4540

Background: Up to now the value of 2nd-line therapy for metastatic gastric cancer is unclear. So far there are no randomized phase III data comparing 2nd-line chemotherapy to BSC. Irinotecan has proven activity in 1st-line therapy. In this randomized phase III study we compared irinotecan to BSC to evaluate the value of 2nd- line chemotherapy for gastric cancer. Methods: Prospective multicenter randomized phase III study, open label. Eligibility: Metastatic or locally advanced gastro-esophageal junction or gastric adenocarcinoma. Objective tumor progession (PD) within 6 months after 1st- line chemotherapy. ECOG PS 0–2. Statistics: Primary endpoint: Overall survival (OS). Hypothesis: H1: OS(Irinotecan)>OS(BSC). Calculated number of pts needed (power 80%, alpha error 5%): 60 pts per arm. Stratification for a) PD less versus (vs) more than 3 months after 1st line chemotherapy, b) ECOG PS 0/1 vs 2. Treatment: Arm A: Irinotecan 250mg/m2 q3w (1st cycle) to be increased to 350 mg/m2, depending on toxicity. Arm B: BSC Results: Between Oct 2002 and Dec 2006 40 pts were randomized. The study was closed prematurely due to poor accrual. Arm A:21 pts, arm B 19 pts. Median age A: 58 yrs (43–73), B: 55 yrs (35–72); PD less vs more than 3 months after 1st-line chemotherapy: A: 18 / 3, B: 17 / 2pts. ECOG PS 0/1 vs 2: A: 17/ 4, B: 14/ 5pts. Pre-treatment with cisplatin: A: 21, B:19 pts. Arm A: 68 cycles administered in 21 pts. Toxicity: (main CTC grade 3/ 4): Nausea 1 pt, vomiting 1 pt, diarrhoea: 5 pts, neutropenic fever: 2 pts, data incomplete 6 pts. In 37% of 19 evaluable pts irinotecan dose was escalated to 350mg/m2. Response (19 pts evaluable): No objective responses, SD 58%, PD 42%. Improvement of tumor related symptoms: 44% of pts in arm A, 5% in arm B. Survival: (evaluable pts arm A 21, arm B 18): median survival arm A: 123 days (95%CI 95–216), arm B 72.5 days (95%CI 41–106); OS: HR=2.85 (95%CI 1.41–5.79), Logrank test (two-sided): p=0.0027. Conclusions: To our knowledge this is the first randomized phase III study investigating 2nd- line chemotherapy in gastric cancer. Irinotecan as 2nd-line chemotherapy significantly prolongs overall survival compared to BSC. 2nd-line chemotherapy can now be considered as a proven option in gastric cancer.

[Table: see text]

[Transjugular intrahepatic portosystemic shunt in patients with portal vein thrombosis]

PURPOSE

To evaluate the feasibility of TIPS for portal vein thrombosis (PVT) with/without portal vein occlusion/cavernomatous transformation and with/without underlying cirrhosis.

MATERIALS AND METHODS

13 patients with PVT and refractory ascites (n=7) and variceal bleeding (n = 6) received TIPS placement. The function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. The rates of technical success, revision and mortality after TIPS were evaluated.

RESULTS

The TIPS was successfully placed in 85% (11/13) of the cases. TIPS placement was successful in 87.5% (7/8) of patients with occlusion of the right portal vein and in 100% (5/5) of patients with non-occlusive right portal vein (p > 0.05), in 80% (8/10) of cirrhotic (x/10) and in 100% (3/3) of non-cirrhotic patients (p > 0,05), as well as in one patient with a fresh PVT and in 1 of 2 patients with cavernous transformation. 30 and 14.3% of patients needed a TIPS revision in the first and second year, respectively. No patient with occlusion of the right portal vein required a revision. 54.5% (6/11) of patients died within 6 months. Under exclusion of 4 patients with advanced malignant diseases, the mortality rate was 28.6%.

CONCLUSION

TIPS should be considered for selected patients with symptomatic occlusive PVT with/without cavernous transformation and with/without underlying cirrhosis. The frequency of TIPS revision is not greater, and the mortality rate 6 months after PVT recanalization seems to be comparable with that of patients without PVT.

MR-guided laser ablation of osteoid osteoma in an open high-field system (1.0 T)

Computed tomography is the standard imaging modality to minimize the extent of surgical or ablative treatment in osteoid osteomas. In the last 15 years, since a description of thermal ablation of osteoid osteomas was first published, this technique has become a treatment of choice for this tumor. We report the case of a 20-year-old man with an osteoid osteoma treated with laser ablation in an open high-field magnetic resonance imaging scanner (1.0 T). The tumor, located in the right fibula, was safely and effectively ablated under online monitoring. We describe the steps of this interventional procedure and discuss related innovative guidance and monitoring features and potential benefits compared with computed tomographic guidance.