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Patidar Y, Srinivasan SV, Singh J, Patel RK, Chandel K, Mukund A, Sharma MK, Sarin SK. Clinical Outcomes of Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate (NBCA) in Cirrhotic Patients. J Clin Exp Hepatol 2022; 12:353-361. [PMID: 35535058 PMCID: PMC9077175 DOI: 10.1016/j.jceh.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To evaluate the clinical outcomes of transcatheter arterial embolization (TAE) with n-butyl-2-cyanoacrylate (NBCA) for treatment of bleeding in cirrhotic patients. Materials and methods A total of 35 cirrhotic patients (26 men, 9 women; mean age, 48.4 ± 11.1) who underwent TAE with NBCA for bleeding from January 2011 to December 2020 were retrospectively analysed. Only cirrhotic patients with active arterial bleeding confirmed on computed tomography (CT) were included. Fifteen patients were hemodynamically unstable before embolization procedure, and coagulopathy was observed in 32 patients. The mean MELD score and Child Pugh score were 24 ± 9.9 and 9.9 ± 2.2, respectively. The mean haemoglobin level and mean number of RBC units transfused before embolization were 7.4 ± 1.4 g/dL and 10.2 ± 4, respectively. The technical, clinical success rate and 30-day mortality rate were evaluated. Results Technical success and clinical success rates were achieved in 100% and 82.8% of patients, respectively. Overall 30-day mortality rate was 48%. No major complications related to the embolization procedure was seen. Only the greater number of RBC units transfused before the embolization procedure (OR = 1.81, 95% CI = 1.17-2.80, P = 0.007) was significantly associated with clinical failure. Greater number of RBC units transfused (OR = 1.53, 95% CI: 1.00-2.34, P = 0.004) and higher Child Pugh score (OR 2.44, 95% CI 1.26-4.71, P = 0.008) were significantly associated with higher 30-day mortality rate. Conclusion Transcatheter arterial embolization using NBCA can be used as the effective treatment option for bleeding in cirrhotic patients which has a high technical and clinical success despite the grave prognosis associated with cirrhosis.
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Key Words
- CT, computed tomography
- INR, international normalized ratio
- IQR, Interquartile range
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- NBCA
- NBCA, N-butyl-2-cyanoacrylate
- OR, Odds ratio
- PVA, polyvinyl alcohol
- RBC, red blood cell
- TAE, transarterial embolization
- acute arterial bleeding
- cirrhotic patients
- coagulopathy
- transcatheter arterial embolization
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Affiliation(s)
- Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Shyam V. Srinivasan
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Jitender Singh
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Ranjan K. Patel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Karamvir Chandel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Manoj K. Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India
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Abstract
Background Spontaneous rupture of hepatocellular carcinoma (HCC) is a potentially fatal complication and the third leading cause of death in patients with HCC after tumor progression and liver failure. Previous studies suggested that improved HCC surveillance has decreased the incidence of rupture. This study aims to characterize patients with ruptured HCC over time and identify predictors of rupture. Methods We retrospectively reviewed a prospectively collected database of 1451 HCC patients to identify cases with rupture and predictors of rupture. Data were divided into three 9-year eras to compare and trend patient/tumor characteristics and rupture. Results Fifty-seven patients (3.9%) presented with spontaneous HCC rupture and the following characteristics: mean age 62.6 years, 73.7% males, 41% cirrhosis, and mean tumor size of 8.0 cm. On multivariate analyses, predictors of rupture included obesity, tumor >5 cm, and single tumors, whereas the presence of cirrhosis was a negative predictor for rupture.Across three eras, there were changes in disease etiology and decreases in tumor size, and more HCCs were found with surveillance. However, more patients were noncirrhotic, and the incidence of spontaneous rupture was unchanged over time. Conclusion Despite improved early detection of HCC over time, the incidence of rupture has been unchanged. The persistent incidence of rupture may possibly be attributed to increasing proportion of fatty liver-related HCC patients who lack traditional risk factors for surveillance and may not have cirrhosis. Better identification of fatty liver disease and determining which patients need HCC surveillance may be needed in the future to prevent spontaneous rupture.
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Key Words
- AFP, alpha fetoprotein
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BMI, Body Mass Index
- HCC, hepatocellular carcinoma
- INR, international normalized ratio
- NAFLD, nonalcoholic fatty liver disease
- NASH, nonalcoholic steatohepatitis
- TACE, transarterial chemoembolization
- TAE, transarterial embolization
- cirrhosis
- fatty liver diseases
- liver resection
- liver tumor
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Affiliation(s)
- Adham E. Obeidat
- Department of Medicine, University of Hawaii John A. Burns School of Medicine. 1356 Lusitana St., UH Tower. Honolulu, HI, 96813, United States
| | - Linda L. Wong
- Department of Surgery, University of Hawaii John A. Burns School of Medicine. 550 South Beretania St., Suite 403. Honolulu, HI, 96813, United States,Address for correspondence. Dr Linda L. Wong, 550 South Beretania St., Suite 403. Honolulu, HI, 96813, United States. Tel.: +808-523-5033, Fax: +808 528 4940.
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Mochizuki Y, Iihoshi S, Tsukagoshi E, Kasakura S, Kohyama S, Kurita H. A rare brainstem hemorrhage due to incomplete transvenous embolization of the cavernous sinus dural arteriovenous fistula: A case report. Radiol Case Rep 2021; 16:2526-2529. [PMID: 34276848 PMCID: PMC8267439 DOI: 10.1016/j.radcr.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022] Open
Abstract
Endovascular embolization is generally thought to be safe and effective for the cavernous sinus dural arteriovenous fistula (CS DAVF); however, some complications have been reported. We report an extremely rare brainstem hemorrhage associated with transvenous embolization (TVE) of CS DAVF. A 66-year-old man presented with right-sided conjunctival chemosis and exophthalmos. His brain magnetic resonance image showed right CS DAVF. Thus, emergent TVE was performed. Although his symptoms improved after the first TVE, magnetic resonance image showed brainstem edema, and venous congestion was suspected because of incomplete TVE. Second TVE was performed. Thereafter, computed tomography showed brainstem hemorrhage, resulting in the occurrence of right abducent nerve palsy, right-sided facial palsy, and ataxia. The patient's condition gradually improved, and a year has passed without recurrence. Incomplete TVE of CS DAVF can result in life-threatening complications, such as cerebral hemorrhage. To avoid these complications, the anatomical structure of the cavernous sinus should be understood accurately, and important drainage veins should be determined.
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Key Words
- Brainstem hemorrhage
- CS, cavernous sinus
- CTA, computed tomography angiography
- Cavernous sinus
- Complication
- DAVF, dural arteriovenous fistula
- DSA, digital subtraction angiography
- Dural arteriovenous fistula
- IPS, inferior petrosal sinus
- MRA, magnetic resonance angiography
- MRI, magnetic resonance imaging
- SMCV, superficial middle cerebral vein
- SOV, superior ophthalmic vein
- SPS, superior petrosal sinus
- TAE, transarterial embolization
- TVE, transvenous embolization
- Transvenous embolization
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Affiliation(s)
- Yoshiki Mochizuki
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
| | - Satoshi Iihoshi
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
| | - Eisuke Tsukagoshi
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
| | - Shigen Kasakura
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
| | - Shinya Kohyama
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
| | - Hiroki Kurita
- Department of Neurosurgery, International Medical Center, Saitama Medical University, 350-1298, Japan
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Federica L, Serafino S, Daniele F, Giovanni F, Stefano P, Antonio B. Endovascular treatment of a rare case of haemobilia caused by both pseudoaneurysm and a giant hepatic haemangioma. Radiol Case Rep 2021; 16:693-697. [PMID: 33488900 PMCID: PMC7809172 DOI: 10.1016/j.radcr.2020.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022] Open
Abstract
Haemobilia is defined as bleeding from the biliary system due to abnormal communication between a blood vessel and the bile ducts. Melena or hematemesis, abdominal pain and jaundice represent the pathognomonic triad for haemobilia, but clinical presentation and aetiology of this entity are extremely variable. We report a case of a 50-year-old man with melena and anaemia and a clinical history of multivalvular endocarditis in which an extremely rare presence of 2 uncommon causes of haemobilia was found, such as a mycotic pseudoaneurysm and a giant hepatic haemangioma, both treated by transarterial embolization. In the management of haemobilia, TAE has been proven to be the treatment of choice because it combines a diagnostic angiography with therapeutic intervention in a minimally invasive, safe and effective way. Physician and radiologist should keep in mind also the uncommon aetiologies of haemobilia, knowing that the source of bleeding could be more than just one.
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Affiliation(s)
- Libra Federica
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
| | - Santonocito Serafino
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
| | - Falsaperla Daniele
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
| | - Failla Giovanni
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
| | - Palmucci Stefano
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
| | - Basile Antonio
- Department of Medical Surgical Sciences and Advanced Technologies - Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Via Santa Sofia 78, Catania, 95123, Italy
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Murayama Y, Hiwatashi A, Murayama R, Shimokawa T, Hidaka H, Tsurumaru D, Honda H. Effectiveness of therapeutic standard concentration barium enema for colonic diverticular bleeding: Preliminary results. Eur J Radiol Open 2019; 6:139-143. [PMID: 31016208 PMCID: PMC6468152 DOI: 10.1016/j.ejro.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/24/2019] [Accepted: 03/29/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the effectiveness of a therapeutic barium enema as a treatment for colonic diverticulum bleeding, by using a standard concentration as a diagnostic examination. Methods We retrospectively analyzed 68 cases of the patients admitted to our hospital with colonic diverticular bleeding between October 2012 and September 2017. We evaluated the following items: (1) the presence/absence of a previous history of diverticular bleeding, (2) the use of medications (anticoagulants, nonsteroidal anti-inflammatory drugs, and antiplatelet drugs), (3) the location of bleeding, (4) the presence/absence of previous treatment and the result, (5) the time between bleeding and the beginning of the barium enema, (6) procedural success, (7) the clinical success of the initial hemostasis, (8) the clinical success of preventing recurrence, and (9) complications such as perforation and diverticulitis associated with this procedure. Results Four patients (three men and one woman; age range 60–85 years; median age 76 years) who underwent therapeutic barium enema with a concentration equivalent for diagnostic purpose (78 w/v%) were included. The follow-up period ranged from 11 to 12 months (median 12 months). All three patients who received a barium enema for initial hemostasis were successfully treated. All four patients remained free from recurrence during the follow-up period. There was no complication due to barium in this series. Conclusion Although we had no statistical evidence, a therapeutic barium enema with a standard concentration as a diagnostic examination may be effective for both the initial hemostasis and preventing the recurrence of colonic diverticular bleeding without complications.
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Affiliation(s)
- Yuriko Murayama
- Department of Radiology, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Akio Hiwatashi
- Departments of Molecular Imaging & Diagnosis, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ryo Murayama
- Department of Radiology, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Tomomi Shimokawa
- Department of Radiology, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Hiromu Hidaka
- Department of Radiology, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Daisuke Tsurumaru
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hiroshi Honda
- Departments of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Abstract
Early diagnosis and aggressive therapy improves outcome in hepatocellular carcinoma (HCC). Several potentially curative as well as palliative treatment options are available for patients. The choice of therapy is influenced by factors such as extent of tumor and severity of underlying liver dysfunction as well as availability of resources and of expertise. A systematic, algorithmic approach would ensure optimal therapy for each patient and is likely to improve outcomes. Even after receiving therapy for HCC, patients remain at risk for recurrent HCC as well as progression of underlying cirrhosis. Proper assessment and monitoring is needed for the underlying liver disease, which may progress to liver failure and have a major impact on long-term survival. Comprehensive care for patients with cirrhosis includes interventions such as antiviral therapy for HBV and HCV, abstention from alcohol, management of fatty liver disease, endoscopic surveillance and treatment for complications of portal hypertension and, if indicated, immunization against HAV and HBV. An algorithmic approach is useful for choosing the most appropriate treatment option for the individual patient from among the various options that are available. The general consensus is that the BCLC system should be preferred for staging HCC as it is useful in predicting outcomes and planning treatment. The BCLC system classifies patients with HCC into five categories: very early, early, intermediate, advanced, and terminal. It incorporates data on tumor status (number and size of nodules, vascular invasion, extra-hepatic spread), liver function (CTP status, presence of portal hypertension) and overall health status (constitutional symptoms, cancer symptoms, performance status). Treatment allocation according to sub-class of patients is a merit of the BCLC system; a few limitations have been noted, particularly with respect to patients with BCLC stage B and C disease. The treatment algorithm as per BCLC system is summarized in this review.
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Key Words
- AJCC–UICC, American Joint Committee on Cancer and Union for International Cancer Control
- ALT, alanine aminotransferase
- BCLC
- BCLC, Barcelona Clinic Liver Cancer
- CEUS, contrast-enhanced ultrasound
- CLIP, Cancer of the Liver Italian Program
- CTP, Child–Turcotte–Pugh criteria
- CUPI, Chinese University Prognostic Index
- EASL, European expert panel
- EBRT, external beam radiotherapy
- HCC, hepatocellular carcinoma
- JIS, Japanese integrated system
- LT, liver transplantation
- MAA, macro-aggregate albumin
- MCT, microwave coagulation therapy
- MWA, microwave ablation
- NCCN, National Comprehensive Cancer Network
- PAI, percutaneous acetic acid injection
- PEI, percutaneous ethanol injection
- PLT, primary LT
- RBV, ribavirin
- RECIST, response evaluation criteria in solid tumors
- RFA, radiofrequency ablation
- SIRT, Selective Internal Radiation Treatment
- SLT, salvage liver transplant
- TACE, trans-catheter arterial chemo-embolization
- TACE-DEB, TACE with drug eluting beads
- TAE, transarterial embolization
- TAI, trans-catheter hepatic arterial infusion
- TARE, transarterial radio-embolization
- TNM, Tumor-Node-Metastasis
- WHO, World Health Organization
- bm-JIS, biomarker JIS
- liver cancer
- staging
- treatment algorithm
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Affiliation(s)
- Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Affiliation(s)
- Mukesh Rathor
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anupam Lal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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