Allan I. Bloom

Clinical Applications of Physical 3D Models Derived From MDCT Data and Created by Rapid Prototyping

OBJECTIVE In this article, we describe the production of physical models from CT data using rapid prototyping and present their clinical application. MDCT data acquisition of isotropic voxels and modern postprocessing techniques provide exquisite detail for clinicians and radiologists. CONCLUSION In recent years, rapid prototyping technologies have provided new possibilities to visualize complex anatomic structures through the generation of physical models that can be used to assist with diagnosis, surgical planning, prosthesis design, and patient communication.

Radiologic Imaging and Intervention for Gastrointestinal and Hepatic Complications of Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is an increasingly available treatment option for patients with various oncologic, hematologic, and immunologic diseases. Although HSCT can be curative for some diseases, complications associated with this treatment limit its success and applicability. Gastrointestinal graft-versus-host disease (GVHD) and hepatic veno-occlusive disease are unique and deadly complications of HSCT. These diseases can mimic other HSCT complications, such as infection, hemorrhage, and hepatotoxicity with cholestasis, but GVHD and veno-occlusive disease require specific treatment. Early treatment improves the probability of treatment success. For these reasons, timely and accurate diagnosis is essential. Abdominal imaging and intervention play an important role in the early, minimally invasive diagnosis and treatment of GVHD and veno-occlusive disease. Imaging findings tend to be nonspecific, but common findings that may guide further management or establish a diagnosis in the clinical setting have been defined. In cases where the diagnosis is unclear and liver biopsy is required, image-guided transvenous liver biopsy may be a safer and more practical option than the transcutaneous approach. Image-guided interventions, including intraarterial steroid-injection therapy in severe, systemic steroid-refractory GVHD and transjugular intrahepatic portosystemic shunt placement in veno-occlusive disease with portal hypertension, have shown some promise in small, uncontrolled series. Larger, controlled studies are needed to define the role of these invasive procedures in this patient population.

Shortening and Migration of Wallstents after Stenting of Central Venous Stenoses in Hemodialysis Patients

Purpose: To report our results for the placement of central venous stents in patients undergoing hemodialysis. Methods: Ten Wallstents (Schneider, Bülach, Switzerland) were placed in 10 patients with shunt thrombosis, shunt dysfunction or arm swelling associated with central vein stenosis or occlusion. Technical success, patency and complications were evaluated. Results: Stent deployment was successful in all cases. In seven cases (70%) there was significant delayed stent shortening. In two of these cases there was also stent migration. All these cases required additional stents. Primary patency rates at 6, 12 and 24 months were 66%, 25% and 0. Twenty-three additional procedures (percutaneous transluminal angioplasty or stenting) were required to achieve secondary patency rates at 6, 12 and 24 months of 100%, 75% and 57%. Conclusion: Stent placement in the central veins of dialysis patients has a high technical success rate resulting in symptomatic relief and preservation of access. Repeat interventions are required to maintain patency. Significant delayed shortening of the Wallstent occurred in 70% of patients which may have affected the patency rates. Strategies are suggested to avoid this problem.

Complications of high grade liver injuries: management and outcomewith focus on bile leaks.

BackgroundAlthough liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively.Patients and methodsThis is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed.ResultsOf 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure.ConclusionsA high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

Hepatic Arterial Injuries after Percutaneous Biliary Interventions in the Era of Laparoscopic Surgery and Liver Transplantation: Experience with 930 Patients

PURPOSE To retrospectively determine if patients with a history of intraoperative bile duct injury or liver transplantation have an increased risk for arterial injury (AI) during percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD) compared with the risk of AI established in the 1970s and 1980s. MATERIALS AND METHODS This study was approved by the committee on human research and was deemed compliant with the Health Insurance Portability and Accountability Act. The informed consent requirement was waived. Records of 1394 procedures (307 PTCs, 1087 PTBDs) performed in 930 patients (445 male, 485 female; age range, 4 months to 99 years) over the past 13 years were retrospectively reviewed. The rate of AI was determined, and demographic, pathologic, technical, and laboratory variables were tested for association with increased risk of AI by using generalized estimating equation analysis. RESULTS AIs were encountered after 30 (2.2%) biliary procedures. No significant difference in the rate of AI was seen among the groups of patients with malignant biliary obstruction (1.8%), history of bile duct injury (2.2%), or complications of liver transplantation (2.6%). Patients who underwent PTBD had a higher risk of AI than did patients who underwent PTC (2.6% vs 0.7%); however, this difference was not significant (P = .06). Ongoing hemobilia was seen in 26 (87%) of the patients, which made it the most common sign of AI, and it had a 94% positive predictive value for AI. A postprocedure decrease in the hematocrit level of more than 13% was seen only in the setting of AI, and it occurred in only three (10%) of patients with AIs. CONCLUSION PTC and PTBD performed for management of bile duct injury and complications of liver transplantation are not associated with an increased risk of hepatic AIs compared with the risk of AI reported in the 1970s and 1980s.

Massive Abdominal Wall Hemorrhage from Injury to the Inferior Epigastric Artery: A Retrospective Review

PURPOSE To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients. MATERIALS AND METHODS A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record. RESULTS Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications. CONCLUSIONS IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.

Reperfusion of Pulmonary Arteriovenous Malformations after Successful Embolotherapy with Vascular Plugs

Amplatzer vascular plugs (AVPs) are among the embolic agents currently used for occlusion of pulmonary arteriovenous malformations (PAVMs). The authors encountered a patient with multiple PAVMs who developed spontaneous reperfusion of two PAVMs within 7 weeks of initially successful embolization with AVPs. Reperfused PAVMs were effectively occluded by coils deposited proximal to the vascular plugs. AVPs do not provide consistent long-term occlusion of the PAVMs. Deposition of coils proximal to the AVP may decrease the chance of PAVM reperfusion after the embolization.

Intra-arterial catheter directed therapy for severe graft-versus-host disease

Summary. Graft‐versus‐host disease (GVHD) is a major complication of allogeneic bone marrow transplantation (BMT), resulting in death in the majority of steroid‐resistant patients. We assessed the efficacy of regional intra‐arterial treatment in patients with resistant hepatic and/or gastrointestinal (GI) GVHD. In total, 15 patients with steroid resistant grade 3–4 hepatic (n = 4), gastrointestinal (GI) (n = 8) GVHD or both (n = 3) were given intra‐arterial treatment. Patients with hepatic GVHD received methotrexate and methylprednisolone into the hepatic artery. Patients with GI GVHD were treated with infusions of methylprednisolone into the superior and inferior mesenteric arteries. Two patients with pronounced upper GI symptoms also received upper GI treatment. In total, 25 procedures were carried out (range 1–3 per patient). Hepatic response was observed in four out of seven (57%) patients with hepatic GVHD, three (43%) featuring good response. Complete responses were observed in nine (82%) GI GVHD patients, with median time to initial and complete response of 3 d (range 1–7) and 15·8 d (range 4–33) respectively. Regional treatment of severe GVHD with intra‐arterial treatment appears to be effective and safe. GI treatment maybe more effective than intrahepatic treatment. Early administration of isolated intra‐arterial therapy in high‐risk patients may further improve the outcome and reduce untoward effects of systemic immunosuppressive treatment.

Trans-arterial chemo-embolization is safe and effective for very elderly patients with hepatocellular carcinoma

AIM To assess the safety and efficacy of trans-arterial chemo-embolization (TACE) in very elderly patients. METHODS A prospective cohort study, from 2001 to 2010, compared clinical outcomes following TACE between patients ≥ 75 years old and younger patients (aged between 65 and 75 years and younger than 65 years) with hepatocellular carcinoma (HCC), diagnosed according to the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases criteria. The decision that patients were not candidates for curative therapy was made by a multidisciplinary HCC team. Data collected included demographics, co-morbidities, liver disease etiology, liver disease severity and the number of procedures. The primary outcome was mortality; secondary outcomes included post-embolization syndrome (nausea, fever, abdominal right upper quadrant pain, increase in liver enzymes with no evidence of sepsis and with a clinical course limited to 3-4 d post procedure) and 30-d complications. Additionally, changes in liver enzyme measurements were assessed [alanine and aspartate aminotransferase (ALT and AST), gamma-glutamyl transpeptidase and alkaline phosphatase] in the week following TACE. Analysis employed both univariate and multivariate methods (Cox regression models). RESULTS Of 102 patients who underwent TACE as sole treatment, 10 patients (9.8%) were > 80 years old at diagnosis; 13 (12.7%) were between 75 and 80 years, 45 (44.1%) were between 65 and 75 years and 34 (33.3%) were younger than 65 years. Survival analysis demonstrated similar survival patterns between the elderly patients and younger patients. Age was also not associated with the adverse event rate. Survival rates at 1, 2 and 3 years from diagnosis were 74%, 37% and 31% among patients < 65 years; 83%, 66% and 48% among patients aged 65 to 75 years; and 86%, 41% and 23% among patients ≥ 75 years. There were no differences between the age groups in the pre-procedural care, including preventive treatment for contrast nephropathy and prophylactic antibiotics. Multivariate survival analysis, controlling for disease stage at diagnosis with the Barcelona Clinic Liver Cancer score, number of TACE procedures, sex and alpha-fetoprotein level at the time of diagnosis, found no significant difference in the mortality hazard for elderly vs younger patients, and there were no differences in post-procedural complications. Serum creatinine levels did not change after 55% of the procedures, in all age groups. In 42% of all procedures, serum creatinine levels increased by no more than 25% above the baseline levels prior to TACE. Overall, there were 69 post-embolization events (23%). Hepatocellular enzymes often increased following TACE, with no association with prognosis. In 40% of the procedures, ALT and AST levels rose by at least 100%. The increases in hepatocellular enzymes occurred similarly in all age groups. CONCLUSION TACE is safe and effective in very elderly patients with HCC, and is not associated with decreased survival or increased complication rates.

Arterial embolisation for persistent primary postpartum haemorrhage: before or after hysterectomy?

Arterial embolisation is a recognised treatment for postpartum haemorrhage (PPH). In this retrospective study, we evaluate its use in the management of persistent PPH. Records of all births during a 54 month period at a university hospital were analysed. Two sub‐groups were identified. Group I (n= 5), underwent embolisation after hysterectomy and Group II (n= 4), had embolisation as a first‐line theraphy without hysterectomy. Of 20,215 births, there were 636 cases of PPH (3.1%). Nine required embolisation to control bleeding (1.4%). Group I needed multiple surgical procedures, had a larger pre‐ and post‐operative blood requirement (12–100, median 22 units, vs. 6–12, median 8.5 units), longer embolisation (33–93, median 54 minutes, vs 20–66, 47 minutes) with a larger radiation exposure (5194–9067, median 6301 dGy, vs. 269–3862, median 950 dGy), a longer intensive care stay (3–7, median four days vs. 0–1.5, median one day), and more complications, when compared with Group II. Three of four women from Group II resumed menstrual function. Embolisation prior to hysterectomy may be preferable to embolisation after hysterectomy for the control of PPH.