Irreversible Electroporation of the Hepatobiliary System: Current Utilization and Future Avenues

Liver cancer remains a leading cause of cancer-related deaths worldwide despite numerous advances in treatment. While surgical resection remains the gold standard for curative treatment, it is only possible for a minority of patients. Thermal ablation is an effective option for the treatment of smaller tumors; however, its use is limited to tumors that are not located in proximity to sensitive structures due to the heat sink effect and the potential of thermal damage. Irreversible electroporation (IRE) is a non-thermal ablative modality that can deliver targeted treatment and the effective destruction of tumors that are in close proximity to or even surrounding vascular or biliary ducts with minimal damage to these structures. IRE produces short pulses of high-frequency energy which opens pores in the lipid bilayer of cells leading to apoptosis and cell death. IRE has been utilized clinically for over a decade in the treatment of liver cancers with multiple studies documenting an acceptable safety profile and high efficacy rates.

Irreversible electroporation as a focal therapy for localized prostate cancer: A systematic review

Introduction

Irreversible electroporation (IRE) is a new and promising focal therapy for the treatment of localized prostate cancer. In this systematic review, we summarize the literature on IRE for prostate cancer published over the last decade.

Methods

PubMed and EMBASE were searched with the end date of May 2023 to find relevant publications on prostate cancer ablation using IRE. Original studies with focal IRE as the primary curative treatment which reported on functional or oncological outcomes were included. The bibliography of relevant studies was also scanned to identify suitable articles.

Results

A total of 14 studies reporting on 899 patients treated with IRE for localized prostate cancer were included. Of all the studies reviewed, 77% reported on recurrence within the zone of ablation, and it ranged from 0% to 38.9% for in-field and 3.6% to 28% for out-of-field recurrence. Although, a standardised follow-up protocol was not followed, all the studies employed serial prostate-specific antigen monitoring, a multiparametric magnetic resonance imaging, and a biopsy (6-12 months post-treatment). Across all the studies, 58% reported that the urinary continence returned to the pretreatment levels and 25% reported a minor decrease in the continence from the baseline at 12-months of follow-up. Erections sufficient for intercourse varied from 44% to 75% at the baseline to 55% to 100% at 12-months of follow-up across all the studies.

Conclusion

IRE, as a focal therapy, shows promising results with minimal complications and reasonably effective oncological control, but the data comparing it to the standard of care is still lacking. Future research should focus on randomized definitive comparisons between IRE, radical prostatectomy, and radiation therapy.

Safety and Efficacy of Percutaneous Liver Microwave Ablation Using a Fully Water-Cooled Choke Ring Antenna: First Multicenter Clinical Report

INTRODUCTION

The safety and efficacy of a microwave ablation (MWA) system for the liver with novel technologies in field control, antenna cooling through the inner part of the choke ring, and dual temperature monitoring were evaluated in this multicenter retrospective study.

MATERIAL AND METHODS

Ablation characteristics and efficacy were assessed on follow-up imaging (computed tomography or magnetic resonance imaging). Safety was evaluated according to CTCAE classification.

RESULTS

Eighty-seven liver tumors (65 metastases and 22 hepatocellular carcinomas) measuring 17.8 ± 7.9 mm were treated in 68 patients. Ablation zones measured 35.6 ± 11 mm in longest diameter. The coefficients of variation of the longest and shortest ablation diameters were 30.1% and 26.4%, respectively. The mean sphericity index of the ablation zone was 0.78 ± 0.14. Seventy-one ablations (82%) had a sphericity index above 0.66. At 1 month, all tumors demonstrated complete ablation with margins of 0-5 mm, 5-10 mm, and greater than 10 mm achieved in 22%, 46%, and 31% of tumors, respectively. After a median follow-up of 10 months, local tumor control was achieved in 84.7% of treated tumors after a single ablation and in 86% after one patient received a second ablation. One grade 3 complication (stress ulcer) occurred, but was unrelated to the procedure. Ablation zone size and geometry in this clinical study were in accordance with previously reported in vivo preclinical findings.

CONCLUSION

Promising results were reported for this MWA device. The high spherical index, reproducibility, and predictability of the resulting treatment zones translated to a high percentage of adequate safety margins, providing good local control rate.

Induction Chemotherapy and Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy for Inoperable Pancreas Cancer

Background

Radiation therapy (RT) dose for inoperable pancreatic ductal adenocarcinoma (PDAC) has historically been non-ablative to avoid injuring gastrointestinal (GI) organs at risk (OARs). Accruing data suggest that dose escalation, in select patients, may significantly improve clinical outcomes. Early results of ablative stereotactic magnetic resonance image-guided adaptive radiation therapy (A-SMART) have been encouraging, although long-term outcomes are not well understood.

Methods

A single institution retrospective analysis was performed of inoperable non-metastatic PDAC patients who received induction chemotherapy then 5-fraction A-SMART on a 0.35T-MR Linac from 2018-2021.

Results

Sixty-two patients were evaluated with a median age of 66 years (range 35-91) and nearly all achieved Eastern Cooperative Oncology Group (ECOG) performance status 0-1 (96.8%). Locally advanced disease was common (72.6%), otherwise borderline resectable (22.6%), or medically inoperable (4.8%). All received induction chemotherapy for a median 4.2 months (range, 0.2-13.3) most commonly FOLFIRINOX (n=43; 69.4%). Median prescribed dose was 50 Gy (range 40-50); median biologically effective dose (BED₁₀) was 100 Gy₁₀. The median local control (LC), progression-free survival (PFS), and overall survival (OS) from diagnosis were not reached, 20 months, and 23 months, respectively. Also, 2-year LC, PFS, and OS were 68.8%, 40.0%, and 45.5%, respectively. Acute and late grade 3+ toxicity rates were 4.8% and 4.8%, respectively.

Conclusions

To our knowledge, this is the largest series of induction chemotherapy followed by ablative 5-fraction SMART delivered on an MR Linac for inoperable PDAC. The potential for this novel treatment strategy is to achieve long-term LC and OS, compared to chemotherapy alone, and warrants prospective evaluation.

Irreversible electroporation for colorectal cancer liver metastasis: a review

Irreversible electroporation (IRE) ablation is gaining popularity over the last decade as a nonthermal alternative to thermal ablation technologies such as radiofrequency ablation (RFA) and Microwave ablation (MWA). This review serves as a practical guide for applying IRE to colorectal cancer liver metastases (CRLM) for interventional radiologists, oncologists, surgeons, and anesthesiologists. It covers patient selection, procedural technique, anesthesia, imaging, and outcomes.

Stent Graft Outcomes in Dialysis Circuits: A Review of Clinical Trials and Literature

End-stage renal disease is a prevalent medical condition causing significant problems as the majority of patients are being treated with dialysis. While dialysis provides a means to compensate for the renal impairment, arteriovenous grafts and fistulas are often complicated by neointimal hyperplasia, loss of primary patency, and graft failure. Over the last decade, stent grafts have emerged as an alternative to balloon angioplasty and bare metal stents for revascularization in the event of arteriovenous graft occlusion or stenosis. Several randomized controlled trials have investigated the efficacy of stent grafts compared with balloon angioplasty for improving the function and durability of dialysis circuits. In this review, we present a comprehensive review of clinical trials. Stent grafts appear to offer increased primary patency over balloon angioplasty in the treatment of dialysis circuit stenosis. However, there is generally no significant difference between the two treatment modalities on other clinically relevant measures like complication rates and overall survival.

Consensus Guidelines for the Definition of Time-to-Event End Points in Image-guided Tumor Ablation: Results of the SIO and DATECAN Initiative

There is currently no consensus regarding preferred clinical outcome measures following image-guided tumor ablation or clear definitions of oncologic end points. This consensus document proposes standardized definitions for a broad range of oncologic outcome measures with recommendations on how to uniformly document, analyze, and report outcomes. The initiative was coordinated by the Society of Interventional Oncology in collaboration with the Definition for the Assessment of Time-to-Event End Points in Cancer Trials, or DATECAN, group. According to predefined criteria, based on experience with clinical trials, an international panel of 62 experts convened. Recommendations were developed using the validated three-step modified Delphi consensus method. Consensus was reached on when to assess outcomes per patient, per session, or per tumor; on starting and ending time and survival time definitions; and on time-to-event end points. Although no consensus was reached on the preferred classification system to report complications, quality of life, and health economics issues, the panel did agree on using the most recent version of a validated patient-reported outcome questionnaire. This article provides a framework of key opinion leader recommendations with the intent to facilitate a clear interpretation of results and standardize worldwide communication. Widespread adoption will improve reproducibility, allow for accurate comparisons, and avoid misinterpretations in the field of interventional oncology research. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Liddell in this issue.

Radioembolization of Secondary Hepatic Malignancies

Cancer has become the leading cause of mortality in America, and the majority of patients eventually develop hepatic metastasis. As liver metastases are frequently unresectable, the value of liver-directed therapies, such as transarterial radioembolization (TARE), has become increasingly recognized as an integral component of patient management. Outcomes after radioembolization of hepatic malignancies vary not only by location of primary malignancy but also by tumor histopathology. This article reviews the outcomes of TARE for the treatment of metastatic colorectal cancer, metastatic breast cancer, and metastatic neuroendocrine tumors, as well as special considerations when treating metastatic disease with TARE.

Irreversible Electroporation for Hepatic Tumors: Protocol Standardization Using the Modified Delphi Technique

PURPOSE

A consensus study of panelists was performed to provide a uniform protocol regarding (contra) indications, procedural parameters, perioperative care, and follow-up of irreversible electroporation (IRE) for the treatment of hepatic malignancies.

MATERIALS AND METHODS

Interventional radiologists who had 2 or more publications on IRE, reporting at least 1 patient cohort in the field of hepatobiliary IRE, were recruited. The 8 panelists were asked to anonymously complete 3 iterative rounds of IRE-focused questionnaires to collect data according to a modified Delphi technique. Consensus was defined as having reached 80% or greater agreement.

RESULTS

Panel members' response rates were 88%, 75%, and 88% in rounds 1, 2, and 3, respectively; consensus was reached on 124 of 136 items (91%). Percutaneous or intraoperative hepatic IRE should be considered for unresectable primary and secondary malignancies that are truly unsuitable for thermal ablation because of proximity to critical structures. Absolute contraindications are ventricular arrhythmias, cardiac stimulation devices, and congestive heart failure of New York Heart Association class 3 or higher. A metal stent outside the ablation zone should not be considered a contraindication. For the only commercially available IRE device, the recommended settings are an inter-electrode distance of 10-20 mm and an exposure length of 20 mm. After 10 test pulses, 90 treatment pulses of 1500 V/cm should be delivered continuously, with a pulse length of 70-90 μs. The first post-procedural follow-up should take place 1 month after IRE and thereafter every 3 months, using cross-sectional imaging plus tumor marker assessment.

CONCLUSIONS

This article provides recommendations, created by a modified Delphi consensus study, regarding patient selection, workup, procedure, and follow-up of IRE treatment for hepatic malignancies.

Hypereosinophilia: A rare presentation of acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) presenting as peripheral blood hypereosinophilia is very rare and the incidence is <1%. The characteristic feature of patients with ALL and hypereosinophilia is the absence of blasts in peripheral blood, and this might lead to misdiagnosis of ALL. It is important for clinicians and pathologists to be aware of this uncommon initial presentation of ALL to avoid delay in diagnosis. We report a 37-year-old man who presented with fever and respiratory symptoms and was found to have hypereosinophilia in peripheral blood. His bone marrow and lymph node biopsies were diagnostic of ALL.

Clinical predictors of arterial extravasation, rebleeding and mortality following angiographic interventions in gastrointestinal bleeding

BACKGROUND AND AIMS

The aim of this study was to identify clinical and imaging predictors of arterial extravasation, post embolization rebleeding and 30-day mortality in gastrointestinal (GI) bleeding.

METHOD

This retrospective study included 114 patients who underwent angiography for upper or lower GI bleeding. Multivariate logistic regression was used to identify clinical and imaging predictors.

RESULTS

Angiography demonstrated arterial extravasation in 22 patients (19%) and embolization was performed in 48 (42%) patients including prophylactic embolization in 26 (56%). Fall in hemoglobin level from baseline was an independent predictor of arterial extravasation with 65% increased odds for every unit drop (OR 1.65, 95%CI 1.13-2.40, p=0.01). Age <60 years was a negative predictor of rebleed within 30-days (OR 0.94, 95%CI 0.89-1.00, p=0.04). Patients with a history of malignancy were more likely to rebleed (OR 4.4, 95%CI 1.06-18.36, p=0.04). Hemodynamic instability prior to angiography (OR 13.22, 95%CI 1.65-106.07, p=0.02), history of malignancy (OR 1.36, 95%CI 1.49-10.49, p=0.01), number of units of platelets transfused (OR 1.42, 95%CI 1.02-1.97, p=0.04) and rebleed after angiography (OR 46.8, 95%CI 4.80-456.14, p<0.01) were predictors of 30-day mortality. Prophylactic embolization was not a predictor of rebleed or 30-day mortality.

CONCLUSIONS

This paper identified important clinical predictors of arterial extravasation, rebleed and 30-day mortality in GI bleedings, which will assist in patient selection and help to improve the overall angiographic management of GI bleeding.

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

PURPOSE

Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution.

METHODS

The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded.

RESULTS

Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT.

CONCLUSION

Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) with a novel radiopaque (RO) drug eluting bead (DEB)

366

Background: Preclinical studies have suggested that RO beads may offer advantages over standard microspheres used for TACE of HCC. The ability to image bead distribution during the procedure is expected to improve the coverage of the tumor minimizing off-target delivery. We conducted a retrospective analysis of efficacy and safety of RO DEB-TACE in patients with HCC. Methods: Forty-eight patients (38 males and 10 females, median age 64 years) with nodular, noninvasive HCC unsuitable for curative treatments, Child-Pugh A (n = 29) or B (n = 19) liver functional status, and ECOG PS 0-1 received DEB-TACE with injection of 2-4 ml of 70-150-micron RO microspheres (LC Bead LUMI; BTG-Biocompatibles) loaded with 37.5 mg/ml doxorubicin. Thirty-seven of 48 patients (77%) had unilobar disease and 11 of 48 (23%) bilobar tumors. The baseline sum tumor diameter was 5.3±2.6 cm (range, 1.2-14.5 cm). The primary endpoint was tumor response by mRECIST. Secondary endpoints were time to progression (TTP), overall survival (OS), and safety. Results: The number of treatments was 1 in 28 patients (58%), 2 in 16 (33%), and 3 in 4 (8%). The mean doxorubicin dose per treatment was 43.9±34.4mg (range, 3.3-150 mg). Best response was CR, PR, SD, and PD in 32, 10, 4 and 2 patients, respectively, for an objective response rate (ORR) of 87.5%. Median TTP was 8.5 months (95% CI, 6.7-not reached). Median OS was not reached in Child class A patients; in class B patients it was 19.5 months (95% CI, 6.0-not reached). There was one treatment-emergent grade 5 AE unrelated to treatment. Grade 3/4 AEs included pain (n = 4), fatigue (n = 2), and fever (n = 1). Grade 3/4 laboratory abnormalities were thrombocytopenia (n = 9), leukopenia (n = 3), elevation of transaminases (n = 3) or bilirubin (n = 3), and anemia (n = 2). Conclusions: In this first clinical study, treatment with RO DEB-TACE resulted in a high ORR and was well tolerated. The encouraging efficacy signal requires confirmation with long-term survival data.

Bowel Obstruction: Decompressive Gastrostomies and Cecostomies

Over the past 30 years, image-guided placement of gastrostomies and cecostomies for gastrointestinal decompression has developed into a safe and effective treatment for symptomatic bowel obstruction. Gastrostomies and cecostomies relieve patient symptoms, can prevent serious complications such as colonic perforation, and may bridge patients to more definitive treatment for the underlying cause of obstruction. This article will review the history of decompressive gastrostomies and cecostomies as well as the indications, contraindications, technique, complications, and outcomes of these procedures.

Prostate Artery Embolization via Transradial or Transulnar versus Transfemoral Arterial Access: Technical Results

PURPOSE

To compare safety and feasibility of prostate artery embolization (PAE) via transradial/transulnar access (TR/UA) and transfemoral access (TFA).

MATERIALS AND METHODS

A retrospective analysis was conducted for 3 cohorts: the first 32 consecutive PAE procedures performed via TFA (initial TFA, January 2014 to August 2015), the following 32 procedures performed via TFA (advanced TFA, August 2015 to February 2016), and the first 32 procedures performed via TR/UA (February 2016 to July 2016). Indications included lower urinary tract symptoms (n = 68), urinary retention (n = 24), and preoperative embolization before prostatectomy (n = 4). A single operator performed all procedures at a single institution.

RESULTS

Technical success was achieved in 29/32 (90.6%) initial TFA procedures, 31/32 (96.9%) advanced TFA procedures, and 30/32 (93.8%) TR/UA procedures. Mean procedure time was 110.0 minutes in TR/UA group, 155.1 min in initial TFA group, and 131.3 minutes in advanced TFA group (P < .01 and P = .03 relative to TR/UA); mean fluoroscopy time was 38.8 minutes in TR/UA group, 56.5 minutes in initial TFA group, and 48.0 minutes in advanced TFA group (P < .01 and P = .02 relative to TR/UA). Access site-related and overall adverse events did not vary significantly among study cohorts (P > .15 and P > .05, respectively).

CONCLUSIONS

TR/UA represents a safe and feasible approach to PAE with a comparable safety profile to TFA. Reduced procedure and fluoroscopy times might be attributable to the learning curve or method of arterial access.

Transarterial embolization of a hyperfunctioning aldosteronoma in a patient with bilateral adrenal nodules

Primary hyperaldosteronism often results in resistant hypertension and hypokalemia, which may lead to cardiovascular and cerebrovascular complications. Although surgery is first line treatment for unilateral functioning aldosteronomas, minimally invasive therapies may be first line for certain patients such as those who cannot tolerate surgery. We present a case of transarterial embolization (TAE) of an aldosteronoma. The patient presented with a cerebrovascular accident, and subsequently developed uncontrolled hypertension, hypokalemia, and a myocardial infarction. Following TAE, potassium returned to normal levels and blood pressure control was improved. There were no postoperative complications. TAE thus may be a safe and effective alternative to surgery.

Transjugular intrahepatic portosystemic shunt for chylous ascites in a patient with recurrent cirrhosis following liver transplantation

Chylous ascites (CA) is the extravasation of lipid-rich lymphatic fluid into the peritoneal space following trauma or obstruction of the lymphatic system. Refractory cases of cirrhosis-related CA may be amendable to transjugular intrahepatic portosystemic shunting (TIPS). We present a case of TIPS in the setting of refractory CA secondary to cirrhosis of a transplanted liver graft. Following TIPS, the patient reported immediate improvement in abdominal pain and no longer requires paracentesis. Our case suggests TIPS to be a safe and effective treatment option for CA in liver transplant patients with cirrhosis.

Percutaneous Image-Guided Irreversible Electroporation for the Treatment of Unresectable, Locally Advanced Pancreatic Adenocarcinoma

PURPOSE

To describe safety and effectiveness of percutaneous irreversible electroporation (IRE) for treatment of unresectable, locally advanced pancreatic adenocarcinoma (LAPC).

MATERIALS AND METHODS

This retrospective study included 50 patients (23 women, 27 men; age range, 46-91 y; median age, 62.5 y) with biopsy-proven, unresectable LAPC who received percutaneous computed tomography (CT)-guided IRE. The primary objective was to assess the safety profile of the procedure; the secondary objective was to determine overall survival (OS). All patients had prior chemotherapy (1-5 lines, median 2), and 30 (60%) of 50 patients had prior radiation therapy. Follow-up included CT at 1 month and at 3-month intervals thereafter.

RESULTS

There were no treatment-related deaths and no 30-day mortality. Serious adverse events occurred in 10 (20%) of 50 patients (abdominal pain [n = 7], pancreatitis [n = 1], sepsis [n = 1], gastric leak [n = 1]). Median OS was 27.0 months (95% confidence interval [CI], 22.7-32.5 months) from time of diagnosis and 14.2 months (95% CI, 9.7-16.2 months) from time of IRE. Patients with tumors ≤ 3 cm (n = 24) had significantly longer median OS than patients with tumors > 3 cm (n = 26): 33.8 vs 22.7 months from time of diagnosis (P = .002) and 16.2 vs 9.9 months from time of IRE (P = .031). Tumor size was confirmed as the only independent predictor of OS at multivariate analysis.

CONCLUSIONS

Percutaneous image-guided IRE of unresectable LAPC is associated with an acceptable safety profile.

Late endovascular removal of Günther-Tulip inferior vena cava filter and stent reconstruction of chronic post-thrombotic iliocaval obstruction after 4753 days of filter dwell time: a case report with review of literature

Chronic post-thrombotic obstruction of the inferior vena cava (IVC) or iliocaval junction is an uncommon complication of long indwelling IVC filter. When such an obstruction is symptomatic, endovascular treatment options include stent placement with or without filter retrieval. Filter retrieval becomes increasingly difficult with longer dwell times. We present a case of symptomatic post-thrombotic obstruction of the iliocaval junction related to Günther-Tulip IVC filter (Cook Medical Inc, Bloomington, IN) with dwell time of 4753 days, treated successfully with endovascular filter removal and stent reconstruction. Filter retrieval and stent reconstruction may be a treatment option in symptomatic patients with filter-related chronic IVC or iliocaval junction obstruction, even after prolonged dwell time.

Amplatzer vascular plug as an embolic agent in different vascular pathologies: A pictorial essay

The Amplatzer Vascular Plug (AVP) is a cylindrical plug made of self-expanding nitinol wire mesh with precise delivery control, which can be used for a variety of vascular pathologies. An AVP is an ideal vascular occlusion device particularly in high-flow vessels, where there is high risk of migration and systemic embolization with traditional occlusion devices. We performed 28 embolizations using the AVP from 2009 to 2014 and achieved complete occlusion without complications.

Pilot Study of Intrahepatic Artery Chemotherapy in Combination with Sorafenib in Hepatocellular Carcinoma

BACKGROUND/AIM

Sorafenib and chemoembolization of the liver (TACE) have both produced increased survival in hepatocellular carcinoma (HCC). Some patients cannot tolerate TACE due to portal vein thrombosis or risk of liver failure. In this pilot trial, we aimed to combine intrahepatic infusion (IA) of cisplatin or carboplatin with sorafenib for unresectable HCC.

PATIENTS AND METHODS

Patients with Child's A or early B received IA cisplatin or carboplatin every 6 weeks with oral sorafenib. MRI/CT scans were performed every 6 weeks.

RESULTS

Eleven patients were accrued. Of 10 evaluable patients, 6 had clinical benefit (4 partial responses for 2+, 3+, 8+ and 18 months, 2 minor responses). Two patients were down-staged enough for ablation therapy or liver transplant and remain free of disease for 32+ and 36+ months. Toxicity was generally tolerable.

CONCLUSION

Preliminary results are encouraging and this combination may down-stage some patients with unresectable disease.

Transsplenic portal vein reconstruction-transjugular intrahepatic portosystemic shunt in a patient with portal and splenic vein thrombosis

Portal vein thrombosis (PVT) is a potential complication of cirrhosis and can worsen outcomes after liver transplant (LT). Portal vein reconstruction-transjugular intrahepatic portosystemic shunt (PVR-TIPS) can restore flow through the portal vein (PV) and facilitate LT by avoiding complex vascular conduits. We present a case of transsplenic PVR-TIPS in the setting of complete PVT and splenic vein (SV) thrombosis. The patient had a 3-year history of PVT complicated by abdominal pain, ascites, and paraesophageal varices. A SV tributary provided access to the main SV and was punctured percutaneously under ultrasound scan guidance. PV access, PV and SV venoplasty, and TIPS placement were successfully performed without complex techniques. The patient underwent LT with successful end-to-end anastomosis of the PVs. Our case suggests transsplenic PVR-TIPS to be a safe and effective alternative to conventional PVR-TIPS in patients with PVT and SV thrombosis.

Prostatic Artery Embolization After Failed Urological Interventions for Benign Prostatic Obstruction: A Case Series of Three Patients

Benign prostate obstruction with associated lower urinary tract symptoms is a common diagnosis with multiple minimally invasive treatment options available. Herein, the authors describe three patients who failed prior different urological interventions who underwent prostate artery embolization with a subsequent improvement in symptoms. The positive response suggests that embolization may be an effective treatment alternative in this subset of patients.

Radiofrequency ablation in primary non-small cell lung cancer: What a radiologist needs to know

Lung cancer continues to be one of the leading causes of death worldwide. In advanced cases of lung cancer, a multimodality approach is often applied, however with poor local control rates. In early non-small cell lung cancer (NSCLC), surgery is the standard of care. Only 15-30% of patients are eligible for surgical resection. Improvements in imaging and treatment delivery systems have provided new tools to better target these tumors. Stereotactic body radiation therapy (SBRT) has evolved as the next best option. The role of radiofrequency ablation (RFA) is also growing. Currently, it is a third-line option in stage 1 NSCLC, when SBRT cannot be performed. More recent studies have demonstrated usefulness in recurrent tumors and some authors have also suggested combination of RFA with other modalities in larger tumors. Following the National Lung Screening Trial (NLST), screening by low-dose computed tomography (CT) has demonstrated high rates of early-stage lung cancer detection in high-risk populations. Hence, even considering the current role of RFA as a third-line option, in view of increasing numbers of occurrences detected, the number of potential RFA candidates may see a steep uptrend. In view of all this, it is imperative that interventional radiologists be familiar with the techniques of lung ablation. The aim of this article is to discuss the procedural technique of RFA in the lung and review the current evidence regarding RFA for NSCLC.

Improved design and development of a functional moulded prosthetic foot

PURPOSE

In the Indian scenario, the Jaipur foot is a low-cost breakthrough that enabled the disabled person to adapt to the Indian environment. The aim of this study is to modify the present foot in terms of ankle support design and method of fabrication, foot moulds profile and the inner core material in order to improve the performance and durability.

METHOD

The optimized design of ankle support and flat foot profile moulds suitable for both left and right foot were developed through CAD/CAM and prosthetic feet were fabricated using ethylene vinyl acetate (EVA) foam as an appropriate alternative core material for microcellular rubber (MCR). The developed prosthetic feet were tested for rigidity by load-deflection analysis in universal testing machine.

RESULT

EVA foot had shown better rigidity than conventional MCR foot, which will help in weight transfer during walking and increase the durability. The CAD modeled ankle support and single block EVA had made the manufacturing process easy and reduced the weight of foot and improved Gait to the person fitted with it due to improved flat foot profile.

CONCLUSION

The new artificial foot had proven to be efficacious technically as well as functionally, which is clearly borne out from the extremely positive feedback given by the amputees. Implications of Rehabilitation Persons with below knee amputation are usually provided with transtibial prosthesis, which allows for easier ambulation and helps them to get back to their normal life. Transtibial prosthesis is an artificial limb that replaces a lower limb that is amputated below the knee. In our study, a new prosthetic foot with a modified ankle support and flat foot profile using better inner-core material than the conventional Jaipur foot was developed and the process was also optimized for mass production. The developed prosthetic foot can be fitted with both above and below knee exoskeleton type of prosthesis.