Abraham Levitin

Comparative Analysis of the Safety and Efficacy of Transcatheter Arterial Chemoembolization and Yttrium-90 Radioembolization in Patients with Unresectable Hepatocellular Carcinoma

PURPOSE To compare retrospectively the safety and efficacy of yttrium-90 ((90)Y) radioembolization with the safety and efficacy of chemoembolization in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS Survival and complication rates were evaluated for patients with HCC who underwent chemoembolization or radioembolization at a single institution between August 2007 and April 2010. Complications were graded according to a standardized grading system for embolization procedures. Survival was determined via the Kaplan-Meier method, and multivariable analysis for factors affecting survival was performed. RESULTS This study included 73 patients with HCC who underwent index embolization with radioembolization (n = 38; 52.1%) or chemoembolization (n = 35; 47.9%). The two patient populations were similar in terms of demographics, etiology of cirrhosis, functional status, tumor characteristics, Child-Pugh class, previous liver-directed therapy, and number of patients with bilirubin > 2.0 mg/dL. There was no significant difference in survival between the radioembolization (median 8.0 months) and chemoembolization (median 10.3 months) cohorts (P = .33). Postembolization syndrome was significantly more severe in patients who underwent chemoembolization, which led to increased total hospitalization rates in these patients. The rates of other complications and rehospitalization were similar between groups. Increased age, Child-Pugh class B, hepatitis seropositivity, bilobar tumor distribution, tumor vascular invasion, and presence of extrahepatic metastases were associated with reduced patient survival. CONCLUSIONS Patients treated with radioembolization did not show a survival advantage over patients treated with chemoembolization. However, patients who underwent chemoembolization had significantly higher rates of hospitalization as a result of postembolization syndrome.

Percutaneous Transrenal Hemodialysis Catheter Insertion

During the course of providing adequate access for hemodialysis, the majority of patients with end-stage renal disease will encounter episodes of catheter dependency. Although catheter-based dialysis is inferior to that obtained through native or synthetic arteriovenous conduits, it is often the only way to provide durable venous access into the central venous circulation system for large volume exchanges. Traditional sites for venous access such as internal/external, subclavian, and common femoral veins will eventually occlude. When alternative percutaneous access sites such as translumbar, transhepatic, and transazygous fail or become less desirable, other approaches become necessary. The authors report a successful case of transrenal access into the renal vein with consequent insertion of a tunneled catheter for hemodialysis in a patient with limited options.

Lung Dose Calculation With SPECT/CT for 90Yittrium Radioembolization of Liver Cancer

PURPOSE To propose a new method to estimate lung mean dose (LMD) using technetium-99m labeled macroaggregated albumin ((99m)Tc-MAA) single photon emission CT (SPECT)/CT for (90)Yttrium radioembolization of liver tumors and to compare the LMD estimated using SPECT/CT with clinical estimates of LMD using planar gamma scintigraphy (PS). METHODS AND MATERIALS Images of 71 patients who had SPECT/CT and PS images of (99m)Tc-MAA acquired before TheraSphere radioembolization of liver cancer were analyzed retrospectively. LMD was calculated from the PS-based lung shunt assuming a lung mass of 1 kg and 50 Gy per GBq of injected activity shunted to the lung. For the SPECT/CT-based estimate, the LMD was calculated with the activity concentration and lung volume derived from SPECT/CT. The effect of attenuation correction and the patients breathing on the calculated LMD was studied with the SPECT/CT. With these effects correctly taken into account in a more rigorous fashion, we compared the LMD calculated with SPECT/CT with the LMD calculated with PS. RESULTS The mean dose to the central region of the lung leads to a more accurate estimate of LMD. Inclusion of the lung region around the diaphragm in the calculation leads to an overestimate of LMD due to the misregistration of the liver activity to the lung from the patients breathing. LMD calculated based on PS is a poor predictor of the actual LMD. For the subpopulation with large lung shunt, the mean overestimation from the PS method for the lung shunt was 170%. CONCLUSIONS A new method of calculating the LMD for TheraSphere and SIR-Spheres radioembolization of liver cancer based on (99m)Tc-MAA SPECT/CT is presented. The new method provides a more accurate estimate of radiation risk to the lungs. For patients with a large lung shunt calculated from PS, a recalculation of LMD based on SPECT/CT is recommended.

Use of Ethylene Vinyl Alcohol Copolymer for Tubal Sterilization by Selective Catheterization in Rabbits

PURPOSE To assess the efficacy of ethylene vinyl alcohol copolymer (Uryx) in nonsurgically occluding the fallopian tube and achieving tubal sterilization in the rabbit model. MATERIALS AND METHODS Ten mature virgin female New England rabbits underwent transvaginal selective bilateral fallopian tube cannulation with use of a coaxial catheter system under general anesthesia. Selective salpingography was performed bilaterally to assess patency of the fallopian tubes. Ethylene vinyl alcohol copolymer was injected unilaterally through a microcatheter to completely fill the middle portion of the tube. Three to seven days after injection, each animal was bred. Conception was determined by ultrasonography (US) 7-19 days after effective breeding. If pregnant, the rabbit was killed. Otherwise, it was permitted to rebreed until pregnancy was achieved. Histologic specimens of the fallopian tubes were prepared and analyzed. RESULTS Patency of the fallopian tubes was demonstrated bilaterally in all animals by the free spillage of contrast material into the peritoneum. The delivery of ethylene vinyl alcohol copolymer into the fallopian tubes was successful in all animals but one, in which most of the plug almost immediately extruded into the uterus. Pregnancy was detected by US in the untreated fallopian tube in the nine rabbits that were receptive to breeding. No pregnancies were detected in the injected side. Histologic analysis demonstrated variable degrees of occlusion, fibrosis, and inflammation, with the majority of specimens demonstrating mild to moderate inflammation and moderate to marked fibrosis. CONCLUSION Ethylene vinyl alcohol copolymer can reliably be placed nonsurgically via the transvaginal approach into the fallopian tubes with use of a coaxial catheter system. Ethylene vinyl alcohol copolymer appears to result in less fibrosis than previously investigated agents and demonstrates a 100% early sterilization rate in the rabbit model.

Penetration of Celect Inferior Vena Cava Filters: Retrospective Review of CT Scans in 265 Patients

OBJECTIVE The purpose of this study is to retrospectively evaluate the prevalence and extent of Celect inferior vena cava (IVC) filter penetration. MATERIALS AND METHODS All patients with Celect filters who underwent CT between 2007 and 2012 were assessed for penetration and related complications. RESULTS Of the 690 patients with Celect filters placed at our institution, 265 underwent CT for various reasons. The mean (SD) interval between filter placement and last CT was 167.8±264.8 days (median, 56 days; range, 0-1592 days). Penetration of primary leg was observed in 39% (95% CI, 29-51%) of patients within 30 days and 80% (95% CI, 70-87%) of patients within 90 days after placement. The mean number of penetrated legs per patient was 1.8 at 30 days and 2.1 at 90 days after placement. Penetration into adjacent organs occurred in 35 of 265 (13.2%) filters (in 45 IVC filter limbs); penetration into two structures occurred with 10 filters. The sites involved were the duodenum (n=22), aorta (n=9), psoas muscle (n=4), vertebral body (n=3), pancreas (n=2), adrenal gland (n=1), liver (n=1), right kidney (n=1), lymph node (n=1), and diaphragm (n=1). One patient presented with abdominal pain related to penetration. CONCLUSION This study confirms a high penetration rate for Celect IVC filters and shows that CT can characterize the extent of leg penetration. Most cases of penetration were asymptomatic, but the likelihood of penetration increased over time.

Combined use of preoperative provocative angiography and highly selective methylene blue injection to localize an occult small-bowel bleeding site in a patient with Crohn's disease report of a case

AbstractPURPOSE: Gastrointestinal bleeding in patients with Crohn’s disease presents both a diagnostic and therapeutic challenge. The bleeding site may be difficult to localize preoperatively and multiple segments of gross disease can lead to uncertainty as to the precise source at the time of laparotomy. METHODS: We describe a patient with Crohn’s disease and recurrent gastrointestinal bleeding in whom the combined use of provocative angiography and highly selective methylene blue injection was used preoperatively to accurately identify the site of hemorrhage and direct bowel resection. RESULTS: Provocative angiography identified the bleeding point in the jejunum. Methylene blue, which had been injected distally into the bleeding vessel during angiography, stained the bowel wall at the bleeding site. Segmental bowel resection was subsequently performed and no further bleeding occurred during the 18-month follow-up period. CONCLUSIONS: The combined use of provocative angiography and highly selective methylene blue injection may aid in the preoperative and intraoperative localization of occult bleeding sites in patients with Crohn’s disease. This allows the bleeding lesion to be removed with a limited resection, thus preserving bowel length.

Predictors of Successful Downstaging of Hepatocellular Carcinoma Outside Milan Criteria

Background Patients with hepatocellular carcinoma (HCC) outside Milan criteria (MC) may be candidates for liver transplantation (LT) after successful downstaging. Factors that predict successful downstaging are unclear. We aimed to identify the predictors of successful downstaging of HCC in patients outside MC. Methods We performed a retrospective cohort study on consecutive patients with HCC outside MC who received downstaging with locoregional therapy. Clinical and laboratory variables, tumor characteristics including total tumor volume (TTV) and up-to-7 criteria were recorded. We performed univariate and multivariate logistic regression analyses to identify variables associated with successful downstaging. Results Of 675 patients with HCC, 90 patients outside MC received downstaging. Fifty-three (59%) patients were successfully downstaged, 37 (41%) failed downstaging. University of California at San Francisco criteria, &agr;-fetoprotein, up-to-7 criteria, TTV, and platelet count were predictors of successful downstaging on univariate analysis. Total tumor volume was an independent predictor of successful downstaging on multivariate logistic regression (P = 0.04, area under receiver operating characteristic curve 0.89 (95% confidence interval, 0.82-0.96). Fifty-two (76%) of 68 patients with TTV less than 200 cm3 were successfully downstaged, whereas only 1 (4.5%) of 22 patients with TTV greater than 200 cm3 were successfully downstaged. Forty-five (50%) patients underwent LT. Kaplan-Meier survival rates at 1 and 5 years post-LT were 95.3% and 79.4%, respectively. Patients who were successfully downstaged had better survival than patients who failed downstaging (P < 0.01). Conclusions Total tumor volume is a good predictor of successful downstaging of HCC. Patients with TTV less than 200 cm3 may be considered good candidates for downstaging. Further studies with larger cohort of patients are needed to validate this approach in patients with HCC outside Milan.

Endovascular technique for revision of excess catheter length in subcutaneous implanted venous access devices.

Abstract To describe the implementation of a technique to trim the excess length of a central venous catheter via a process of endovascular snaring without exposing or changing the device. We report on the outcome of this technique in 3 patients. The technique was successful in two cases and successful with a modification in the remaining case. The technique is useful to salvage an implanted venous access device. It appears to be less invasive with reduced procedure time and less patient discomfort than other techniques.

Macroaggregated albumin injected in hepatic artery visualized in a recanalized paraumbilical vein.

Treating liver tumors with yttrium-90 radioembolization is a relatively new method. Before performing radioembolization, we inject Tc-99m macroaggregated albumin (MAA) in hepatic artery and calculate hepatopulmonary shunting of blood using planar imaging; and analyze MAA distribution using SPECT/CT. We present an interesting finding where SPECT/CT images revealed activity associated with a linear structure just beneath the right anterior abdominal wall. Triphasic CT images obtained few days ago revealed that the linear structure was recanalized paraumbilical vein. To our knowledge, this is the first case demonstrating portosystemic shunt in the form of a recanalized paraumbilical vein on Tc-99m MAA pretherapy scan.

Pulmonary Thromboendarterectomy in the Setting of a Mediastinal Venous Malformation with a Congenitally Absent Left Subclavian Vein

Venous malformations have static venous lakes that predispose to spontaneous venous thrombosis within the malformation due to its low-flow static state. Thrombi of varying sizes can then embolize continually into the pulmonary arterial circulation, and occlude and narrow elastic pulmonary arteries causing chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary thromboendarterectomy (PTE) is potentially curative in CTEPH, but has not been previously reported in the setting of mediastinal and chest wall venous malformations. We report the case of a 21-year-old female with such a large malformation treated successfully with PTE. The patient underwent complete endovascular reconstruction of her subclavian vein system from the axillary vein to the innominate vein stump with covered stent grafts to exclude the malformations from causing recurrent pulmonary emboli. This was followed by embolization of the malformation to allow for the surgical approach. The series of events in this case serves as a novel approach in managing such rare patients.