Partial Splenic Embolization in Paediatric Sickle Cell Disease Patients with Hypersplenism

PURPOSE

To assess the safety and efficacy of partial splenic embolization (PSE) to reduce the need of transfusions and improve hematologic parameters in patients with hypersplenism and sickle cell disease (SCD).

MATERIAL AND METHODS

This prospective study includes 35 homozygous hemoglobin S patients with SCD and hypersplenism who underwent PSE from 2015 until 2021 in Kinshasa. Patients were evaluated, before and after PSE (1, 3 and 6 months), using clinical, laboratory and ultrasonographic methods. PSE was performed with the administration of gelatin sponge particles embolizing 60-70% of the splenic parenchyma.

RESULTS

The mean age was 10 (± 4) years and (21/35, 60%) were male. After PSE Leucocytes decreased at 3 months (16 692.94 vs 13 582.86, p = 0.02) and at six months Erythrocytes increased 2 004 000 vs. 2 804 142 (p < 0.001), Platelets increased (168 147 vs. 308 445, p < 0.001) and Hemoglobin increased (5.05 g/dL vs. 6.31 g/dL, p < 0.001) There was a significant dicrease in the need of transfusions from 6 (2-20) before PSE to 0.06 (0-1) after PSE (p < 0.001). The most frequent complication was splenic rupture (4/35, 11.4%), seen only and in all patients with hypoechogenic nodules at baseline.

CONCLUSION

PSE is a safe procedure in patients with SCD and hypersplenism, that do not have hypoechogenic nodules in the spleen. PSE improves the hematological parameters and reduces the frequency of blood transfusions.

Predictive Factors for Adverse Event Outcomes After Transarterial Radioembolization with Yttrium-90 Resin Microspheres in Europe: Results from the Prospective Observational CIRT Study

BACKGROUND

Using data collected in the prospective observational study CIRSE Registry for SIR-Spheres Therapy, the present study aimed at identifying predictors of adverse events (AEs) following transarterial radioembolization (TARE) with Yttrium-90 resin microspheres for liver tumours.

METHODS

We analysed 1027 patients enrolled between January 2015 and December 2017 and followed up for 24 months. Four hundred and twenty-two patients with hepatocellular carcinoma (HCC), 120 with intrahepatic carcinoma (ICC), 237 with colorectal liver metastases and 248 with liver metastases from other primaries were included. Prognostic factors were calculated with a univariable analysis by using the overall AEs burden score (AEBS).

RESULTS

All-cause AEs were reported in 401/1027 (39.1%) patients, with AEs associated with TARE, such as abdominal pain (16.6%), fatigue (17%), and nausea (11.7%) reported most frequently. Grade 3 or higher AEs were reported in 92/1027 (9%) patients. Reports on grade ≥ 3 gastrointestinal ulcerations (0.4%), gastritis (0.3%), radiation cholecystitis (0.2%) or radioembolization-induced liver disease (0.5%) were uncommon. Univariable analysis showed that in HCC, AEBS increased for Eastern Cooperative Oncology Group (ECOG) 0 (p = 0.0045), 1 tumour nodule (0.0081),  > 1 TARE treatment (p = 0.0224), no prophylactic embolization (p = 0.0211), partition model dosimetry (p = 0.0007) and unilobar treatment target (0.0032). For ICC,  > 1 TARE treatment was associated with an increase in AEBS (p = 0.0224), and for colorectal liver metastases, ECOG 0 (p = 0.0188), > 2 prior systemic treatments (p = 0.0127), and 1 tumour nodule (p = 0.0155) were associated with an increased AEBS.

CONCLUSION

Our study confirms that TARE is a safe treatment with low toxicity and a minimal impact on quality of life.

Pure laparoscopic major liver resection after yttrium90 radioembolization: a case-matched series analysis of feasibility and outcomes

Background

Liver surgery after radioembolization (RE) entails highly demanding and challenging procedures due to the frequent combination of large tumors, severe RE-related adhesions, and the necessity of conducting major hepatectomies. Laparoscopic liver resection (LLR) and its associated advantages could provide benefits, as yet unreported, to these patients. The current study evaluated feasibility, morbidity, mortality, and survival outcomes for major laparoscopic liver resection after radioembolization.

Material and methods

In this retrospective, single-center study patients diagnosed with hepatocellular carcinoma, intrahepatic cholangiocarcinoma or metastases from colorectal cancer undergoing major laparoscopic hepatectomy after RE were identified from institutional databases. They were matched (1:2) on several pre-operative characteristics to a group of patients that underwent major LLR for the same malignancies during the same period but without previous RE.

Results

From March 2011 to November 2020, 9 patients underwent a major LLR after RE. No differences were observed in intraoperative blood loss (50 vs. 150 ml; p = 0.621), operative time (478 vs. 407 min; p = 0.135) or pedicle clamping time (90.5 vs 74 min; p = 0.133) between the post-RE LLR and the matched group. Similarly, no differences were observed on hospital stay (median 3 vs. 4 days; p = 0.300), Clavien–Dindo ≥ III complications (2 vs. 1 cases; p = 0.250), specific liver morbidity (1 vs. 1 case p = 1.000), or 90 day mortality (0 vs. 0; p = 1.000).

Conclusion

The laparoscopic approach for post radioembolization patients may be a feasible and safe procedure with excellent surgical and oncological outcomes and meets the current standards for laparoscopic liver resections. Further studies with larger series are needed to confirm the results herein presented.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02474-z.

A new animal model of atrophy-hypertrophy complex and liver damage following Yttrium-90 lobar selective internal radiation therapy in rabbits

Lobar selective internal radiation therapy (SIRT) is widely used to treat liver tumors inducing atrophy of the treated lobe and contralateral hypertrophy. The lack of animal model has precluded further investigations to improve this treatment. We developed an animal model of liver damage and atrophy–hypertrophy complex after SIRT. Three groups of 5–8 rabbits received transportal SIRT with Yttrium 90 resin microspheres of the cranial lobes with different activities (0.3, 0.6 and 1.2 GBq), corresponding to predicted absorbed radiation dose of 200, 400 and 800 Gy, respectively. Another group received non-loaded microspheres (sham group). Cranial and caudal lobes volumes were assessed using CT volumetry before, 15 and 30 days after SIRT. Liver biochemistry, histopathology and gene expression were evaluated. Four untreated rabbits were used as controls for gene expression studies. All animals receiving 1.2 GBq were euthanized due to clinical deterioration. Cranial SIRT with 0.6 GBq induced caudal lobe hypertrophy after 15 days (median increase 34% -ns-) but produced significant toxicity. Cranial SIRT with 0.3 GBq induced caudal lobe hypertrophy after 30 days (median increase 82%, p = 0.04). No volumetric changes were detected in sham group. Transient increase in serum transaminases was detected in all treated groups returning to normal values at 15 days. There was dose-dependent liver dysfunction with bilirubin elevation and albumin decrease. Histologically, 1.2 GBq group developed permanent severe liver damage with massive necrosis, 0.6 and 0.3 GBq groups developed moderate damage with inflammation and portal fibrosis at 15 days, partially recovering at 30 days. There was no difference in the expression of hepatocyte function and differentiation genes between 0.3 GBq and control groups. Cranial SIRT with 0.3 GBq of ⁹⁰Y resin microspheres in rabbits is a reliable animal model to analyse the atrophy–hypertrophy complex and liver damage without toxicity.

Immuno-oncology and interventional oncology: a winning combination. The latest scientific evidence

OBJECTIVE

Interventional oncology (IO) is an emergent field in interventional radiology that can be considered the fourth pillar of oncology. Interventional oncology has the unique capability to treat malignancy in a loco-regional fashion enabling curative (percutaneous ablation), disease stabilization (intra-arterial chemo/radioembolization), and palliative treatment (such as biliary drainage or nephrostomy). The whole arsenal of IO acts by inducing necrosis and apoptosis, with interactions with the tumour's microenvironment potentially crucial for oncological outcomes. Considering that tumour's microenvironment is a pivotal target for both immuno-oncology and interventional-oncology, the interactions between these two anti-tumour weapons must be investigated to understand their synergy. Interestingly, substantial efforts have been directed to understand which technique combinations are best for specific tumours. This review article summarizes the latest scientific evidence highlighting the future prospective of this winning combination, integrating evidence-reported literature and experience-based perceptions.

Clinical Application of Radioembolization in Hepatic Malignancies: Protocol for a Prospective Multicenter Observational Study

Background

Radioembolization, also known as transarterial radioembolization or selective internal radiation therapy with yttrium-90 (90Y) resin microspheres, is an established treatment modality for patients with primary and secondary liver tumors. However, large-scale prospective observational data on the application of this treatment in a real-life clinical setting is lacking.

Objective

The main objective is to collect data on the clinical application of radioembolization with 90Y resin microspheres to improve the understanding of the impact of this treatment modality in its routine practice setting.

Methods

Eligible patients are 18 years or older and receiving radioembolization for primary and secondary liver tumors as part of routine practice, as well as have signed informed consent. Data is collected at baseline, directly after treatment, and at every 3-month follow-up until 24 months or study exit. The primary objective of the Cardiovascular and Interventional Radiological Society of Europe Registry for SIR-Spheres Therapy (CIRT) is to observe the clinical application of radioembolization. Secondary objectives include safety, effectiveness in terms of overall survival, progression-free survival (PFS), liver-specific PFS, imaging response, and change in quality of life.

Results

Between January 2015 and December 2017, 1047 patients were included in the study. The 24-month follow-up period ended in December 2019. The first results are expected in the third quarter of 2020.

Conclusions

The CIRT is the largest observational study on radioembolization to date and will provide valuable insights to the clinical application of this treatment modality and its real-life outcomes.

Trial Registration

ClinicalTrials.gov NCT02305459; https://clinicaltrials.gov/ct2/show/NCT02305459

International Registered Report Identifier (IRRID)

DERR1-10.2196/16296

Hepatic Flow Redistribution is Feasible in Patients with Hepatic Malignancies Undergoing Same-Day Work-Up Angiography and Yttrium-90 Microsphere Radioembolization

PURPOSE

To assess the feasibility of performing same-day vascular flow redistribution and Yttrium-90 radioembolization (90Y-RE) for hepatic malignancies.

MATERIALS AND METHODS

From November 2015 to February 2019, patients undergoing same-day hepatic flow redistribution during work-up angiography, ^99mTechnetium-labeled macroaggregated albumin (^99mTc-MAA) SPECT/CT and 90Y microsphere-RE, were recruited. Within 18 h following the delivery of 90Y resin microspheres, an 90Y-PET/CT study was performed. According to patients' vascular anatomy, flow redistribution was performed by microcoil embolization of extrahepatic branches (group A), intrahepatic non-tumoral vessels (group B) and intrahepatic tumoral arteries (group C). The accumulation of ^99mTc-MAA particles and microspheres in the redistributed areas was qualitatively evaluated using a 5-point visual scale (grade 1 = < 25% accumulation; grade 5 = 100% accumulation). Differences in the distribution of microspheres among groups were assessed with Mann-Whitney U test.

RESULTS

Twenty-two patients were treated for primary (n = 17) and secondary (n = 5) hepatic malignancies. The MAA-SPECT/CT showed uptake in all the redistributed areas. Regarding the accumulation of microspheres within the redistributed segments in all the groups, perfusion patterns were classified as 2 in 1 case, 4 in 6 cases and 5 in 15 cases. No statistically significant differences were observed between groups A and B-C (U value = 34, p = 0.32) and between groups B and C (U value = 26, p = 0.7). Mean predicted absorbed doses by the tumoral and normal hepatic tissues were 163.5 ± 131.2 Gy and 60.4 ± 69.3 Gy, respectively. Mean total procedure time (from work-up angiography to 90Y delivery) was 401 ± 0.055 min.

CONCLUSION

Performing same-day redistribution of the arterial hepatic flow to the target and 90Y-microsphere delivery is feasible in the treatment of liver tumors. Clinical Trials Registry NCT03380130.

The ten commandments of chemoembolization: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017

Transarterial therapies in the setting of primary and secondary liver malignancies are becoming an essential part of the oncology landscape. The mechanism of action of c-TACE is the induction of tumor necrosis due to the high concentration of the chemotherapeutic that is delivered only locally and to the embolic effect that causes ischemia and increased dwell time of the chemotherapeutic in the tumor. Recently, DEB-TACE has emerged as a variation of c-TACE with the potential for the selective delivery of large amounts of drugs to the tumor for a prolonged period, thereby decreasing plasma levels of the chemotherapeutic agent and related systemic effects. There is an increasing consensus that compared with conventional lipiodol-based regimen, DEB-TACE offers standardized methodology, is more reproducible and is associated with improved response and significantly better safety profile. Using an easy to access point by point format, this manuscript summarizes the expert discussion from the Mediterranean Interventional Oncology Live Congress (MIOLive 2017) about the role of TACE in the treatment of liver tumors.

Selective internal radiation therapy: an effective treatment for hormonal syndromes in pancreatic neuroendocrine tumors

The hormone secretion in pancreatic neuroendocrine tumors (pNET) causes an important interference in patients' quality of life. We present two cases of pNET metastatic to the liver (a pancreatic endocrine carcinoma with a severe hormonal syndrome and an insulinoma with severe crisis of hypoglycemia and coma) refractory to conventional treatments, which were finally solved with selective internal radiation therapy (SIRT), a nonstandard level 1 therapy. We show two examples of an excellent control of symptoms together with a long survival after treatment with SIRT. The evidence supporting the use of this therapy is level 2. Our case reports strongly support the use of SIRT for the severe clinical syndrome in pNET metastatic to the liver and refractory to somatostatin analogs.

The ten commandments of liver ablation: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017

Percutaneous liver ablation has become a cornerstone of the recently developed subspecialty of radiology - that is, interventional oncology. Thermal ablation technology has evolved rapidly during the past decades, with substantial technical and procedural improvements that can help obtain better clinical outcomes and safety profiles. Due to the widespread use of percutaneous ablation, a comprehensive review of the methodologic and technical considerations seems to be mandatory. This article summarizes the expert discussion and report from Mediterranean Interventional Oncology Live Congress (MIOLive 2017) that was held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions, to assist not only residents and fellows who are training in interventional radiology but also practicing colleagues who are approaching to this locoregional treatment.

Pneumatocele during sorafenib therapy: first report of an unusual complication

Sorafenib is a multi-kinase inhibitor and a vascular endothelial growth factor (VEGF) inhibitor approved to treat patients with advanced hepatocellular carcinoma, renal cell carcinoma and differentiated thyroid carcinoma. Its most common side effects are asthenia/fatigue, skin toxicity, diarrhea and arterial hypertension. Reported respiratory adverse reactions include dyspnea, cough, pleural effusion and hoarseness. The aim of this report is to describe for the first time the occurrence of pneumatocele in two patients treated with Sorafenib. Patients had no respiratory symptoms and alternative diagnoses were ruled out. Primary tumors were different (liver metastases from a pancreatic neuroendocrine tumor and hepatocellular carcinoma) but both patients had been treated with yttrium 90 radioembolization 9 and 17 months before starting on Sorafenib, respectively. No complications occurred and Sorafenib withdrawal was followed by radiologic improvement.

Hepatocellular carcinoma treatment: ablation and arterial embolization

Percutaneous and endovascular techniques take an important role in the therapeutic management of patients with hepatocarcinoma. Different techniques of percutaneous ablation, especially indicated in tumors up to 2cm diameter offer, at least, similar results to surgical resection. Taking advantage of double hepatic vascularization and exclusive tumor nutrition by the artery, several endovascular techniques of treating the tumor have been developed. Intra-arterial administration of embolizing particles, alone or charged with drug (chemoembolization), will produce ischemia and consequent necrosis with excellent results in selected patients. Certain types of particles may exclusively be carriers of a therapeutic agent when they incorporate a radioisotope that facilitates the direct intratumoral selective irradiation (radioembolization). This technique has demonstrated its efficacy in lesions not susceptible to be treated with other methods and should be considered, together with ablation and chemoembolization, in the therapeutic algorithms of hepatocarcinoma.

The Post-SIR-Spheres Surgery Study (P4S): Retrospective Analysis of Safety Following Hepatic Resection or Transplantation in Patients Previously Treated with Selective Internal Radiation Therapy with Yttrium-90 Resin Microspheres

BACKGROUND

Reports show that selective internal radiation therapy (SIRT) may downsize inoperable liver tumors to resection or transplantation, or enable a bridge-to-transplant. A small-cohort study found that long-term survival in patients undergoing resection following SIRT appears possible but no robust studies on postsurgical safety outcomes exist. The Post-SIR-Spheres Surgery Study was an international, multicenter, retrospective study to assess safety outcomes of liver resection or transplantation following SIRT with yttrium-90 (Y-90) resin microspheres (SIR-Spheres^®; Sirtex).

METHODS

Data were captured retrospectively at participating SIRT centers, with Y-90 resin microspheres, surgery (resection or transplantation), and follow-up for all eligible patients. Primary endpoints were perioperative and 90-day postoperative morbidity and mortality. Standard statistical methods were used.

RESULTS

The study included 100 patients [hepatocellular carcinoma: 49; metastatic colorectal cancer (mCRC): 30; cholangiocarcinoma, metastatic neuroendocrine tumor, other: 7 each]; 36% of patients had one or more lines of chemotherapy pre-SIRT. Sixty-three percent of patients had comorbidities, including hypertension (44%), diabetes (26%), and cardiopathy (16%). Post-SIRT, 71 patients were resected and 29 received a liver transplant. Grade 3+ peri/postoperative complications and any grade of liver failure were experienced by 24 and 7% of patients, respectively. Four patients died <90 days postsurgery; all were trisectionectomies (mCRC: 3; cholangiocarcinoma: 1) and typically had one or more previous chemotherapy lines and presurgical comorbidities.

CONCLUSIONS

In 100 patients undergoing liver surgery after receiving SIRT, mortality and complication rates appeared acceptable given the risk profile of the recruited patients.

The Post-SIR-Spheres Surgery Study (P4S): Retrospective Analysis of Safety Following Hepatic Resection or Transplantation in Patients Previously Treated with Selective Internal Radiation Therapy with Yttrium-90 Resin Microspheres

BACKGROUND

Reports show that selective internal radiation therapy (SIRT) may downsize inoperable liver tumors to resection or transplantation, or enable a bridge-to-transplant. A small-cohort study found that long-term survival in patients undergoing resection following SIRT appears possible but no robust studies on postsurgical safety outcomes exist. The Post-SIR-Spheres Surgery Study was an international, multicenter, retrospective study to assess safety outcomes of liver resection or transplantation following SIRT with yttrium-90 (Y-90) resin microspheres (SIR-Spheres^®; Sirtex).

METHODS

Data were captured retrospectively at participating SIRT centers, with Y-90 resin microspheres, surgery (resection or transplantation), and follow-up for all eligible patients. Primary endpoints were perioperative and 90-day postoperative morbidity and mortality. Standard statistical methods were used.

RESULTS

The study included 100 patients [hepatocellular carcinoma: 49; metastatic colorectal cancer (mCRC): 30; cholangiocarcinoma, metastatic neuroendocrine tumor, other: 7 each]; 36% of patients had one or more lines of chemotherapy pre-SIRT. Sixty-three percent of patients had comorbidities, including hypertension (44%), diabetes (26%), and cardiopathy (16%). Post-SIRT, 71 patients were resected and 29 received a liver transplant. Grade 3+ peri/postoperative complications and any grade of liver failure were experienced by 24 and 7% of patients, respectively. Four patients died <90 days postsurgery; all were trisectionectomies (mCRC: 3; cholangiocarcinoma: 1) and typically had one or more previous chemotherapy lines and presurgical comorbidities.

CONCLUSIONS

In 100 patients undergoing liver surgery after receiving SIRT, mortality and complication rates appeared acceptable given the risk profile of the recruited patients.

[Ionizing radiation received by patients with osteosarcoma during intra-arterial chemotherapy treatment]

BACKGROUND

Osteosarcoma paediatric patients are usually treated with intra-arterial chemotherapy (QTia) which is admi-nistered directly to the tumour. This procedure exposes patients to ionizing radiation. Paediatric patients are especially sensitive to this exposure.

METHODS

The total amount of ionizing radiation received from QTia administration was quantified in a group of 16 osteo-sarcoma paediatric patients from the Clínica Universidad de Navarra.

RESULTS

The median of the total radiation received per patient was 33.4 Gy·cm2 (IQR: 43.33 Gy·cm2), and the median number of procedures performed per subject was 10 (IQR: 6.5).

CONCLUSIONS

The study highlights the importance of quantifying the radiation received by a group of children and adoles-cents affected by osteosarcoma during treatment with QTia. Long-term side effects of this radiation should be considered in pae-diatric patients. Currently, there are no previous studies that provide data of the amount of ionizing radiation received through this procedure.

Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents

OBJECTIVES

To analyze the safety and efficacy of percutaneous placement of coated self-expanding metallic stents (SEMS) in patients with biliary leaks.

MATERIAL AND METHODS

This ethics committee at our center approved this study. We retrospectively reviewed all coated SEMS placed between October 2008 and September 2015. We analyzed patient-related factors such as the primary underlying disease, prior hepatic procedures, and clinical outcome. We evaluated the location, the number and type of leak (anastomotic or non-anastomotic), and the characteristics of the interventional procedure (number of stents deployed, location of the stents, technical success, and primary functionality). We recorded the complications registered.

RESULTS

We studied 14 patients (11 men and 3 women). The mean follow-up period was 375.5 days (range 15-1920 days). Leaks were postsurgical in 12 patients. One patient developed an arteriobilioportal fistula. In another, the biliary leak occurred secondary to the rupture of the common bile duct after ERCP. A total of 23 coated SEMS were placed, including 21 Fluency^® stents (Bard, Tempe, AZ, USA) and 2 Wallflex^® stents (Boston Scientific, Galway, Republic of Ireland). The technical success of the procedure was considered total in 11 (78.6%) patients, partial in 2 (14.3%) patients, and null in 1 (7.2%) patient. The clinical outcome was good in 13 of the 14 patients. The mean period of primary functionality of the coated SEMS was 331 days (range 15-1920 days). No major complications were observed in 11 (78.6%) patients.

CONCLUSIONS

Percutaneous placement of coated SEMS for the treatment of benign biliary leaks is safe and efficacious, with a high rate of technical and clinical success and a moderate rate of complications.

Segmental arterial mediolysis: findings at computed tomography angiography

OBJECTIVE

To review the principal findings on computed tomography angiography for segmental arterial mediolysis, and to emphasize the points that help to differentiate it from other vasculopathies such as vasculitis. We also review the protocols for follow-up and the various treatment options.

CONCLUSION

Segmental arterial mediolysis is a rare disease that is defined as a non-atherosclerotic, non-hereditary, and non-inflammatory vasculopathy characterized by lysis of the medial layer of the arterial wall. It should be suspected in middle-aged patients with aneurysms, dissections, or spontaneous ruptures of visceral arteries of unknown etiology who do not fulfill the clinical and laboratory criteria for vasculitis. The arteries of the abdominal organs are the most commonly affected, including the arteries of the celiac trunk and the superior and inferior mesenteric arteries. Radiologically, segmental arterial mediolysis can present as arterial dilation; single or multiple, saccular or fusiform aneurysms; stenoses; or dissections.

Hepatic venous outflow obstruction after transplantation: outcomes for treatment with self-expanding stents

OBJECTIVES

To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction.

MATERIAL AND METHODS

This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction.

RESULTS

The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P=.091).

CONCLUSIONS

Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction.

Efficacy of transjugular intrahepatic portosystemic shunt to prevent total portal vein thrombosis in cirrhotic patients awaiting for liver transplantation

INTRODUCTION

Complete portal vein thrombosis (PVT) may complicate orthotopic liver transplantation (OLT), increasing its technical difficulty and the transfusion requirements and as well as affecting survival in some cases. Transjugular intrahepatic portosystemic shunt (TIPS) prevents total portal vein occlusion in patients with partial PVT.

OBJECTIVE

We aimed to assess the efficacy and safety of TIPS to prevent total portal vein occlusion among patients listed for OLT.

PATIENTS AND METHODS

We analyzed the clinical records of 15 consecutive patients with partial PVT who underwent TIPS before OLT. The control group consisted of 8 transplanted patients without TIPS but partial PVT diagnosed before OLT. Portal vein patency at surgery, ischemia time, and transfusion requirements during OLT, and survival thereafter were compared between both groups. The main complications were also compared: mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, and technical complications during the 6 months after OLT.

RESULTS

Clinical characteristics at the time of OLT were similar between the groups. No relevant complications were observed after TIPS; all patients underwent transplantation. One- and 5-year actuarial survival rates were similar in both groups (92% and 85% in TIPS-group versus 100 and 75% in the control group, respectively). No differences in transfusion requirement, duration of ischemia, and frequency of technical complications during and after OLT were observed between the groups. The portal vein was patent at surgery in all TIPS patients and 4 of 8 (50%) in the control group (P = .008).

CONCLUSION

TIPS may prevent PVT in liver transplantation candidates with partial PVT.

Complications of embolization

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Prognosis of hepatocellular carcinoma in relation to treatment across BCLC stages

BACKGROUND

The Barcelona Clinic Liver Cancer (BCLC) staging system recommends first-line therapy for each tumor stage. We evaluated the effect of compliance with BCLC treatment allocation on the prognosis of patients with hepatocellular carcinoma (HCC).

METHODS

We retrospectively analyzed 359 consecutive, newly diagnosed HCC patients treated in our Liver Unit during a 14-year period. For each stage, survival was compared according to whether treatment matched the BCLC recommendation. We also compared the survival of patients in the same BCLC stage who received different treatments, and patients in different BCLC stages receiving the same treatment.

RESULTS

BCLC-A patients treated with radical therapies (66%) survived longer (117 vs. 20 months; p < 0.001) than patients (33%) who received locoregional or systemic therapies. Survival of BCLC-B patients treated with locoregional treatments (57%) was shorter (24 vs. 71 months; p < 0.001) than that of patients receiving radical therapies (32%). BCLC-C patients treated with systemic therapy or supportive care survived shorter (6 vs. 11 months; p = 0.003) than those receiving locoregional therapies (39%). Survival of BCLC-D patients receiving systemic therapies or supportive care was significantly lower than that of patients treated by liver transplantation (5 vs. 137 months; p < 0.001).

CONCLUSIONS

In addition to BCLC stage, actual treatment determines survival in patients with HCC.

Safety and efficacy assessment of flow redistribution by occlusion of intrahepatic vessels prior to radioembolization in the treatment of liver tumors

We evaluated the feasibility, safety, and efficacy of radioembolization (administered from one or two vascular points) after the redistribution of arterial blood flow in the liver in patients with hepatic neoplasms and arterial anatomic peculiarities (AAP). Twenty-four patients with liver neoplasms and AAP (graded according to Michel's classification) were included in the study. During pretreatment angiographic planning, all extrahepatic vessels that could feed the tumor were embolized and the intrahepatic vessels occluded in order to redistribute blood flow. The distribution of microspheres was initially assessed by using technetium-99m-labeled macroaggregated albumin ((99m)Tc-MAA) from one of two vascular points before the administration of yttrium-90 ((90)Y)-radiolabeled resin microspheres. Perfusion of lesions situated in the redistributed segments (L-RS) and nonredistributed segments (L-NRS) were compared by assessing the distribution of (99m)Tc-MAA by SPECT/CT. Perfusion was graded as normal, reduced, or absent. (90)Y resin microspheres were then injected from the same arterial sites as (99m)Tc-MAA and the tumor response recorded 3 months later. The tumor response in L-RS was compared with that in L-NRS and graded as better, similar, or worse. Among 11 patients with type I AAP in whom mainly vessels in segments I-III or IV were occluded, perfusion of L-RS was graded as similar (n = 7) or reduced (n = 4). Among the remaining 13 patients with AAP types III (n = 3), V (n = 4), VIII (n = 3), and others (n = 3) in which aberrant arteries were occluded, perfusion of L-RS was graded as similar (n = 9), reduced (n = 3), or absent (n = 1). Overall, (99m)Tc-MAA was present in the L-RS of 95.8% patients and the distribution of (99m)Tc-MAA in L-RS and L-NRS were graded as similar in 66.6% of patients. Compared with lesions in the L-NRS, tumor response in L-RS was similar in 23 cases and worse in 1 case. No complications were recorded after the administration of (90)Y resin microspheres. Redistribution of flow in L-RS is feasible and enables a safe and effective delivery of (90)Y resin microspheres that are able to be distributed via intrahepatic collaterals and access the microvasculature of L-RS.

Biocompatibility, inflammatory response, and recannalization characteristics of nonradioactive resin microspheres: histological findings

Intra-arterial radiotherapy with yttrium-90 microspheres (radioembolization) is a therapeutic procedure exclusively applied to the liver that allows the direct delivery of high-dose radiation to liver tumors, by means of endovascular catheters, selectively placed within the tumor vasculature. The aim of the study was to describe the distribution of spheres within the precapillaries, inflammatory response, and recannalization characteristics after embolization with nonradioactive resin microspheres in the kidney and liver. We performed a partial embolization of the liver and kidney vessels in nine white pigs. The left renal and left hepatic arteries were catheterized and filled with nonradioactive resin microspheres. Embolization was defined as the initiation of near-stasis of blood flow, rather than total occlusion of the vessels. The hepatic circulation was not isolated so that the effects of reflux of microspheres into stomach could be observed. Animals were sacrificed at 48 h, 4 weeks, and 8 weeks, and tissue samples from the kidney, liver, lung, and stomach evaluated. Microscopic evaluation revealed clusters of 10–30 microspheres (15–30 μm in diameter) in the small vessels of the kidney (the arciform arteries, vasa recti, and glomerular afferent vessels) and liver. Aggregates were associated with focal ischemia and mild vascular wall damage. Occlusion of the small vessels was associated with a mild perivascular inflammatory reaction. After filling of the left hepatic artery with microspheres, there was some evidence of arteriovenous shunting into the lungs, and one case of cholecystitis and one case of marked gastritis and ulceration at the site of arterial occlusion due to the presence of clusters of microspheres. Beyond 48 h, microspheres were progressively integrated into the vascular wall by phagocytosis and the lumen recannalized. Eight-week evaluation found that the perivascular inflammatory reaction was mild. Liver cell damage, bile duct injury, and portal space fibrosis were not observed. In conclusion, resin microspheres (15–30 μm diameter) trigger virtually no inflammatory response in target tissues (liver and kidney). Clusters rather than individual microspheres were associated with a mild to moderate perivascular inflammatory reaction. There was no evidence of either a prolonged inflammatory reaction or fibrosis in the liver parenchyma following recannalization.

[Arterial microcoil embolization in high flow priapism]

High flow priapism occurs mainly as a result of a posttraumatic arteriocavernous fistula. Treatment aims to seal the fistula without damaging erectile function. Of all the available treatments, supraselective embolization of the lacerated artery achieves optimal sealing of the fistula with minimal damage to the surrounding tissues. There is no consensus regarding the best materials to be used. Although reabsorbable materials have traditionally been the most commonly used, it is also possible to achieve adequate resolution of the priapism with adequate conservation of erectile function using non-reabsorbable materials, especially microcoils. We describe two cases of patients with high flow priapism caused by bilateral arteriocavernous fistulas treated using microcoil embolization.

Intervascular Anastomoses Created by an Endovascular Approach: Technical Aspects and Initial Results in an Animal Study

PURPOSE

The current article describes the initial results after the creation of intervascular connections with use of an exclusively endovascular approach. Connections of two vessels were performed in the thoracic and abdominal areas with use of a kinematic needle without traversing a solid organ. The materials developed specifically for this technique are described.

MATERIALS AND METHODS

The procedure was carried out in 11 animals and consisted of bringing together two vascular structures with use of magnets, performing a puncture from the lumen of one vessel to that of the other, and inserting a prosthesis between the two. The prosthesis has a biconical morphology and is made with a 0.016-inch monofilament of nitinol. Its most outstanding feature is that, when it is dilated with a balloon, it shortens and "rolls up," flattening its ends. This allows good fixation to the vessel wall, avoiding the protrusion of metal into the lumen of the native vessel.

RESULTS

On four occasions, the aorta was connected to another nearby vessel: the abdominal aorta to the inferior vena cava (IVC; n = 1), the ascending aorta to the trunk of the pulmonary artery (n = 1), and the descending aorta to the left pulmonary artery (n = 2). On another four occasions, two veins were connected: the portal vein and the IVC. Finally, on three occasions, the right pulmonary artery was connected to the superior vena cava. The connection was safely and accurately performed with passage of a guide wire in all cases. In two experiments, the prosthesis was too short and leakage with massive bleeding was observed after a successful initial deployment of the prosthesis

CONCLUSION

Intervascular anastomoses created by an endovascular approach are feasible in the authors' experimental model for several different vessel pairings.

[Endovascular therapeutic techniques]

Percutaneous and endovascular techniques have shown their efficacy in the treatment of a great variety of pathologies. The advances in diagnostic imaging as well as the development of new materials have made it possible to carry out new procedures that were unthinkable not many years ago. The irruption of this new form of treating patients has had, is having, and will have a clear impact on the multidisciplinary approach to numerous diseases.

Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients

PURPOSE

To present a series of cases of non-cirrhotic patients with symptomatic massive portal thrombosis treated by percutaneous techniques. All patients underwent a TIPS procedure in order to maintain the patency of the portal vein by facilitating the outflow.

METHODS

A total of six patients were treated for thrombosis of the main portal vein (6/6); the main right and left branches (3/6) and the splenic vein (5/6) and superior mesenteric vein (6/6). Two patients had a pancreatic malignancy; one patient with an orthotopic liver transplant had been surgically treated for a pancreatic carcinoma. Two patients had idiopathic thrombocytosis, and in the remaining patient no cause for the portal thrombosis was identified. During the initial procedure in each patient one or more approaches were tried: transhepatic (5/6), transileocolic (1/6), trans-splenic (1/6) or transjugular (1/6). In all cases the procedure was completed with a TIPS with either ultrasound guidance (3/6), "gun-shot" technique (2/6) or fluoroscopic guidance (1/6).

RESULTS

No complications were observed during the procedures. One patient had a repeat episode of variceal bleeding at 30 months, one patient remained asymptomatic and was lost to follow-up at 24 months, two patients were successfully treated surgically (cephalic duodenopancreatectomy) and are alive at 4 and 36 months. One patient remains asymptomatic (without new episodes of abdominal pain) at 16 months of follow-up. One patient died because of tumor progression at 10 months.

CONCLUSION

Percutaneous techniques for portal recanalization are an interesting alternative even in non-acute thrombosis. Once flow has been restored in the portal vein TIPS may be necessary to obtain an adequate outflow, hence facilitating and maintaining the portal flow.

The role of transjugular intrahepatic portosystemic shunt prior to abdominal tumoral surgery in cirrhotic patients with portal hypertension

INTRODUCTION

Major abdominal surgery can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of three patients with abdominal tumours prepared for surgery by transjugular intrahepatic portosystemic shunts (TIPS) in order to reduce portal hypertension and the risk of intraoperative bleeding.

PATIENTS AND METHODS

Three patients with cirrhosis and portal hypertension diagnosed with a right colon carcinoma, an adenocarcinoma of pancreas and a gastric and sigmoid synchronic tumours in the same patient. Because portal hypertension was the leading cause of surgical contraindication, neoadjuvant TIPS placement was proposed before surgery.

RESULTS

TIPS placement was performed without intra-procedure complications. An average reduction of 18 mmHg was achieved in portosystemic gradients. The planned operations were performed with a delay of 14-45 days after TIPS without intraoperative bleeding. Complications occurred in one patient without operative mortality.

CONCLUSION

TIPS placement allows a pre-operative portal decompression in cirrhotic patients with portal hypertension and abdominal tumours that require surgical treatment. This procedure reduces the risk of bleeding by reducing the portosystemic gradient and the varices around the tumoral area. This procedure is less invasive than conventional shunt surgery, but it is not free of complications and should be performed by experienced interventional radiologists on selected patients. This is still an experimental indication of TIPS which efficacy must be confirmed in larger series.

Percutaneous Extrahepatic Portacaval Shunt with Covered Prostheses: Feasibility Study

PURPOSE

To assess the anatomic feasibility of creating a percutaneous extrahepatic portosystemic shunt (PEPS) between the main portal vein (MPV) and the inferior vena cava (IVC) in patients with cirrhosis and to evaluate the feasibility of this approach in an animal model.

MATERIALS AND METHODS

In human studies, computed tomographic (CT) scans from 34 patients with cirrhosis were reviewed to assess the distance and anatomic structures found between the MPV and IVC. The MPV was divided into upper, middle, and lower thirds for analysis. In the experimental model, PEPS were created in 10 beagle dogs by placing between the MPV and IVC a tubular polyurethane-covered prosthesis with flared ends designed for this study. Different approaches, devices, and prostheses were assayed.

RESULTS

In human studies, the shortest mean distance between the IVC and the MPV was found in the lower third of the MPV (1.18 cm +/- 0.6). The lower third, the nearest to the confluence of splenic and superior mesenteric veins, also presented fewer intervening structures, and the spatial relationship between the veins at this level was predictable. In the experimental model, direct portography was performed, with a small mesenteric vein catheterized through a minilaparotomy and a transjugular access to the IVC. A needle was advanced from the MPV to the IVC, and a polyurethane cone-shaped covered prosthesis was placed to bridge the path between the veins. Six of 10 animals died from bleeding that occurred either because several punctures were made during the procedure or because the prosthesis became dislodged when the mesentery was moved before suturing the minilaparotomy. The remaining four were kept alive for 1, 5, 60, and 90 days after the procedure.

CONCLUSIONS

PEPS creation in patients with cirrhosis is anatomically possible. The lower third of the MPV should be the most suitable level at which to create the shunt. Preliminary studies carried out in beagle dogs support the feasibility of this approach. However, further work is needed to improve the efficacy of this technique.

Non-traumatic abdominal emergencies: imaging and intervention in gastrointestinal hemorrhage and ischemia

Radiologist and radiological techniques play a crucial role in imaging and interventional procedures in gastrointestinal hemorrhage and ischemia. They are involved in emergency situations that may lead to the death of the patient. Therefore correct diagnosis and treatment are absolutely decisive. We have a great potential in tools of diagnosis, with angiography serving not only as the gold standard for diagnosis even offering a potentially effective treatment for various pathologies. Nevertheless, other techniques have developed greatly during the past decade, including in standard protocols for the management of vascular pathologies such as those discussed here. Ultrasound, computed tomography, and magnetic resonance imaging and their applications in the vascular field such as in as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography provide sensitivity as high as that of angiography for detecting vascular-dependent lesions and for evaluating and excluding other causes of acute or chronic abdomen disorders. This contribution evaluates clinical aspects, various imaging techniques, and interventional effectiveness related to gastrointestinal hemorrhage and ischemia.

CO(2) wedged hepatic venography: technical considerations and comparison with direct and indirect portography with iodinated contrast

BACKGROUND

We evaluated the efficacy and safety of CO(2) wedged hepatic venography (CO(2) WHV) by comparing it with direct transjugular (DP) and indirect arterial portography (IP).

METHODS

Twenty-one CO(2) WHV and IP examinations were performed in 20 patients; 13 of them also underwent DP within 48 h of CO(2) WHV and IP. IP involved the injection of iodinated contrast into the superior mesenteric and splenic arteries. DP was performed from a transjugular approach, during transjugular intrahepatic portosystem shunt placement, with the injection of iodinated contrast into the superior mesenteric or splenic vein. The parameters evaluated were visualization of vessels and varices, portal vein thrombosis detection, and complications.

RESULTS

CO(2) WHV depicted the splenic vein in 57%, the superior mesenteric vein in 62%, the main portal vein in 90%, the right portal vein in 95%, and the left portal vein in 90% of patients. It also demonstrated gastroesophageal varices in seven cases, a splenorenal shunt in one case, mesenteric varices in one case, and a recanalized umbilical vein in one case; other varices were also seen.

CONCLUSION

CO(2) WHV is a good and safe technique for demonstrating the portal circulation. It may provide information not obtainable by IP and DP. However, IP provides better demonstration of the variceal network.

Central venous catheter placement in the inferior vena cava via the direct translumbar approach

The aim of this study was to evaluate the technical aspects and efficacy of placing tunneled central venous access catheters (CVA) in the inferior vena cava (IVC) via a direct translumbar approach. Between August 1994 and July 1998, 50 CVA (Hickman 13.5 F) were placed in the IVC via a direct translumbar approach in 46 patients (10 males, 36 females) with a mean age of 39.9 years (age range 10-87 years). The indications were chemotherapy administration plus leukoaphoresis (n = 39), bone marrow transplantation (n = 2) and hemodialysis (n = 5). The reasons for placing the CVA in the IVC were cosmetic (n = 34), supradiaphragmatic venous thrombosis (n = 8), previous catheter infection (n = 2), and non-functioning arteriovenous fistula (n = 2). There were no immediate complications. The mean period of time the CVA was in place was 3 months (15 days to 15 months), during which the function was excellent. The commonest late complication was infection (4 local, 6 bacteremia). Others included: pain (n = 2), ureteric fistula (n = 1), pericatheter fibrin sheath formation (n = 6) and catheter-tip impaction (n = 2). Two catheters were damaged due to postprocedural inappropriate manipulations and two others fell off due to incorrect fixation. Due to these complications, it was necessary to remove ten catheters, replace an additional four and reposition two. Direct translumbar catheterization of the IVC is a safe and effective way of placing a long-term CVA with a moderate complication rate.

Ascites due to anastomotic stenosis after liver transplantation using the piggyback technique: treatment with endovascular prosthesis

Liver transplantation preserving the retrohepatic inferior vena cava, the so-called piggyback technique, is becoming more frequently used because it avoids caval cross-clamping during the anhepatic phase of surgery. However, hepatic venous outflow blockade causing ascites seems to be less infrequent after piggyback than with cavo-caval anastomosis. We report a 62-year-old patient who underwent liver transplantation using the piggyback technique and developed a stenosis in the anastomosis between the hepatic veins and the inferior vena cava leading to severe postoperative ascites. Ascites was unresponsive to diuretic therapy and was associated with renal function impairment. Since the etiology of the stenosis was mechanical (torsion), percutaneous transluminal angioplasty was unsuccessful. Finally, an autoexpandable prosthesis was placed across the anastomosis resulting in rapid and permanent (3 years of follow-up) resolution of ascites.

Limitations of percutaneous techniques in the treatment of portal vein thrombosis

New therapeutic alternatives to portal vein thrombosis (PVT) include the percutaneous, transhepatic infusion of fibrinolytic agents, balloon dilatation, and stenting. These maneuvers have proven to be effective in some cases with acute, recent PVT. We have treated two patients with acute PVT via transhepatic or transjugular approaches and by using pharmacologic and mechanical thrombolysis and thrombectomy. Although both patients clinically improved, morphologic results were only fair and partial rethrombosis was observed. The limitations of percutaneous procedures in the recanalization of acute PVT in noncirrhotic patients are discussed.

Interventional therapeutic techniques in Budd-Chiari syndrome

PURPOSE

To analyze the results obtained with percutaneous therapeutic procedures in patients with Budd-Chiari syndrome (BCHS).

METHODS

Between August 1991 and April 1993, seven patients with BCHS were treated in our hospital. Three presented with a congenital web; in another three cases the hepatic veins and/or the inferior vena cava (IVC) were compromised after major hepatic surgery; one patient presented with a severe stenosis of the intrahepatic IVC due to hepatomegaly.

RESULTS

One of the patients with congenital web has required several new dilatations due to restenosis; one patient required a transjugular intrahepatic portosystemic shunt procedure while awaiting a liver transplantation. The two postsurgical patients with stenosed hepatic veins did not require any new procedure after the placement of metallic endoprostheses. However, the patient with liver transplantation presented IVC restenosis after balloon angioplasty that required the deployment of metallic endoprostheses. In the patient with hepatomegaly a self-expandable prosthesis was placed in the intrahepatic portion of the IVC before (4 months) a liver transplantation.

CONCLUSION

Interventional therapeutic techniques offer a wide variety of possibilities for the treatment of patients with BCHS. For IVC stenoses, the results obtained with balloon angioplasty are at least as good as those obtained with surgery.

Embolization of nonvariceal portosystemic collaterals in transjugular intrahepatic portosystemic shunts

Percutaneous embolization of large portosystemic collaterals was performed in three patients following placement of a transjugular intrahepatic portosystemic shunt in order to improve hepatopetal portal flow. Improved hepatic portal perfusion was achieved in these cases, thereby theoretically reducing the risk of chronic hepatic encephalopathy.