Operator learning curve for transradial liver cancer embolization: implications for the initiation of a transradial access program

PURPOSE

We aimed to analyze transradial access (TRA) learning curve on patients undergoing hepatic chemoembolization, investigating the relationship between procedural volumes and various benchmarks of procedural success.

METHODS

We enrolled 60 consecutive patients who received two unilobar hepatic chemoembolizations within a 4-week interval performed by a single interventional radiologist, highly-trained in conventional transfemoral access (TFA) procedures, but without any previous practical experience in TRA procedures and with a preliminary 2-day theoretical training only. Consecutive patients were prospectively enrolled and analyzed in 3 groups: A (cases 1 to 20), B (cases 21 to 40), and C (cases 41 to 60). All patients underwent one hepatic chemoembolization using TRA and the other one using TFA in random order. All TFA procedures performed by the same operator in the same series of patients were considered as the control group. Primary endpoint was to analyze the relationship between TRA procedure operator experience and benchmarks of procedural success, to define the optimal procedural learning curve.

RESULTS

Technical success was obtained in all patients, with a crossover rate (radial to femoral access) of 0%. An association between incremental TRA operator experience (in terms of performed procedures) and decrease of preparation, puncture, fluoroscopy, and total examination times was observed. Similarly, inverse associations between incremental TRA operator experience and contrast medium (CM) volumes (P < 0.001) and radiation dose (RD) values (in terms of RAK - Reference Air Kerma) (P < 0.001) were also observed. Compared with TFA, CM volumes and RD values were significantly higher only in group A (cases 1-20). Procedure success remained high in all TRA groups and no significant association between TRA incremental experience and postprocedural outcomes was found. Higher postprocedural complaints at the access route and more limitations in performing basic activities were recorded after TFA vs. TRA (P < 0.001).

CONCLUSION

TRA catheterizations can be safely performed in patients treated for liver cancer embolization after a relatively short training in controlled conditions and with a better performance in comparison with TFA. Operator proficiency improves with greater TRA experience, with a threshold needed to overcome the learning curve represented by about 20 procedures.

TACE with degradable starch microspheres (DSM-TACE) as second-line treatment in HCC patients dismissing or ineligible for sorafenib

OBJECTIVES

To date, there is no approved second-line treatment for patients dismissing sorafenib or ineligible for this treatment, so it would be useful to find an effective alternative treatment option. The aim of our study was to evaluate safety, feasibility and effectiveness of transarterial chemoembolisation with degradable starch microspheres (DSM-TACE) in the treatment of patients with advanced hepatocellular carcinoma (HCC) dismissing or ineligible for multikinase-inhibitor chemotherapy administration (sorafenib) due to unbearable side effects or clinical contraindications.

METHODS

Forty consecutive BCLC stage B or C patients (31 male; age, 70.6 ± 13.6 years), with intermediate or locally advanced HCC dismissing or ineligible for sorafenib administration, who underwent DSM-TACE treatment cycle via lobar approach were prospectively enrolled. Tumour response was evaluated on multidetector computed tomography based on mRECIST criteria. Primary endpoints were safety, tolerance and overall disease control (ODC); secondary endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

Technical success was achieved in all patients. No intra/peri-procedural death/major complications occurred. No signs of liver failure or systemic toxicity were detected. At 1-year follow-up, ODC of 52.5% was registered. PFS was 6.4 months with a median OS of 11.3 months.

CONCLUSIONS

DSM-TACE is safe and effective as a second-line treatment in HCC patients dismissing or ineligible for sorafenib.

KEY POINTS

• DSM-TACE is safe and effective as second-line treatment in HCC patients dismissing or ineligible for sorafenib • DSM-TACE allows the temporary occlusion of the smaller arterial vessels, improving overall therapeutic effectiveness by reducing the immediate wash-out of the cytostatic agent • DSM-TACE also decreases the risk of systemic toxicity and post-embolic syndrome.

Transarterial chemoembolization with degradable starch microspheres (DSM-TACE): an alternative option for advanced HCC patients? Preliminary results

OBJECTIVE

To assess safety, feasibility and effectiveness of transarterial chemoembolization with degradable-starch-microspheres (DSM-TACE) in the treatment of patients with advanced hepatocellular carcinoma (HCC) dismissing or ineligible for multikinase-inhibitor chemotherapy administration (Sorafenib) due to unbearable side effects or clinical contraindications.

PATIENTS AND METHODS

Six consecutive advanced HCC patients dismissing Sorafenib because of unbearable side effects or worsened clinical conditions were enrolled in our prospective single-center pilot study. DSM-TACE was performed via a lobar approach, based on extent and distribution of the disease (1 treatment session for every lobe involved, with a 2-week interval in case of bilobar disease). Tumor response based on mRECIST criteria was evaluated on MD-CT performed at 1 month after "complete treatment" and every 3 months thereafter.

RESULTS

Eleven treatments were performed, and technical success was achieved in all patients. No intra/peri-procedural death/major complications occurred. No signs of liver failure or systemic toxicity were detected. At one month follow-up, 5 partial responses (83.3%) and 1 progression disease (16.6%) with an overall disease control (ODC) of 83.3% were observed. In two patients with ODC and residual viable tumor higher than 50%, a repeated DSM-TACE treatment was performed. During the mean follow-up of 11 months (range: 4-14 months), an ODC of 66.6% was obtained. Progression-free survival was 5.5 months with a cumulative 6-month and 1-year overall survival rates of 83.3% and 66.6%, respectively.

CONCLUSIONS

DSM-TACE seems to be a promising option for advanced HCC patients ineligible for Sorafenib administration or dismissing it due to progressive disease or unbearable side effects.

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Causes of death in patients with unipolar single chamber ventricular pacing: prevalence and circumstances in dependence on arrhythmias leading to pacemaker implantation

Cardiac pacing improves the prognosis of patients with severe impulse formation and conduction disturbance, though sudden death can occur frequently in paced patients. In the present study, we analyzed the causes and the circumstances of 378 deaths in 2,243 paced patients followed over a 5-year period. Sudden cardiac death occurred in 71 of these 378 patients (18.7%), 56 patients died of stroke (15%), heart failure was the cause of death in 91 subjects (24%). We analyzed the causes of death in two groups with respect to the arrhythmia that had led to pacemaker implantation. The prevalence of cardiac sudden death was higher in patients with AV block than in patients with sick sinus syndrome, while stroke was more frequent in patients with sick sinus syndrome, particularly those with both fast and slow components. Atrial fibrillation is common in patients with sick sinus syndrome and is an important well-known risk factor for stroke. Death from heart failure was frequently reported in our population, but in our study group only a few patients had heart failure at the moment of pacemaker implantation. We conclude that sudden death is a common event in paced patients and the disturbance that led the patient to pacemaker implantation was also a factor in the cause of death.