Diaphragmatic Weakness after Transcatheter Arterial Chemoembolization of Inferior Phrenic Artery for Treatment of Hepatocellular Carcinoma

PURPOSE

To prospectively assess the diaphragmatic anatomic and functional consequences of transcatheter arterial chemoembolization (TACE) of the inferior phrenic artery in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Informed consent and institutional review board approval were obtained. Fifteen patients (13 men, two women; mean age, 52 years; age range, 22-61 years) who underwent TACE of the inferior phrenic artery for treatment of hepatocellular carcinoma were enrolled. The right inferior phrenic artery was embolized in 14 patients, and the left inferior phrenic artery was embolized in one patient. Chest radiography, fluoroscopy, computed tomography (CT), and pulmonary function tests were performed before and after TACE of the inferior phrenic artery. The post-TACE examinations were performed 2-3 months after TACE, and the results were compared with those of the pre-TACE examinations. A paired t test or the Wilcoxon signed rank test was used for statistical analyses.

RESULTS

At chest radiography and fluoroscopy, six of 15 patients (40%) had both elevation and movement abnormality of the ipsilateral hemidiaphragm after TACE of the inferior phrenic artery. The mean (+/- standard deviation) diaphragmatic thickness on CT scans changed from 9.11 mm +/- 3.02 to 7.67 mm +/- 2.27 after TACE (P = .048). The mean vital capacity also was significantly decreased after TACE, from 91.87% +/- 18.52 to 82.27% +/- 16.94 of the predicted value (P = .006). The decreases in diaphragmatic thickness and vital capacity were most pronounced in the patients with abnormal findings at chest radiography and fluoroscopy.

CONCLUSION

After TACE of the inferior phrenic artery, a substantial portion of patients showed functional and anatomic evidence of diaphragmatic weakness.

Salvage of immature arteriovenous fistulas with percutaneous transluminal angioplasty

The purpose of this study was to assess the value of percutaneous transluminal angioplasty (PTA) for the salvage of arteriovenous fistulas (AVFs) that fail to mature. From November 1998 to February 2003, 19 patients who were treated with PTA due to immature forearm AVFs were selected. Fistulography and PTA were performed via a retrograde transvenous approach after direct puncture of the fistular vein. Technical success was defined as less than a 30% residual stenosis, whereas clinical success was defined as the ability to perform at least one session of normal hemodialysis after PTA. Findings of fistulograms, success rates of PTA, and patency rates were evaluated. On initial fistulograms, stenoses were observed in all cases and 68% (13/19) of the stenoses were located in the perianastomotic area of these immature AVFs. The initial technical success rate was 84% (16/19). Technical failures comprised two patients with diffuse narrowing and segmental thrombosis of the cephalic veins and one case of elastic recoil of the anastomotic site stenosis after PTA. Two patients were immediately lost on follow-up. The remaining 14 cases underwent successful hemodialysis 0 to 33 (mean = 15) days after PTA, showing 74% (14/19) clinical success. Although accessory branch veins were noted in most cases (74%, 14/19), leaving them alone did not affect the maturation of AVFs following PTA. There was no significant procedural or late complication. Primary and secondary patency rates at 1 year were 61 and 82%, respectively. For those AVFs that failed to mature, there were stenoses along their vascular courses as underlying causes. For the percutaneous procedure, the retrograde transvenous approach was a reasonable one. As PTA is effective and quick for the salvation of immature AVFs, it can be considered a primary method for salvaging these immature AVFs.