Celal Cinar

Evaluation of Treatment Response of Chemoembolization in Hepatocellular Carcinoma with Diffusion-Weighted Imaging on 3.0-T MR Imaging

PURPOSE To assess the treatment response of hepatocellular carcinoma (HCC) after transarterial chemoembolization with diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance (MR) imaging with a 3-T system. MATERIALS AND METHODS Between February 2010 and November 2010, 74 patients were treated with chemoembolization in our interventional radiology unit. Twenty-two patients (29%) who had liver MR imaging including diffusion and dynamic contrast-enhanced MR imaging on a 3-T system before and after transarterial chemoembolization were evaluated retrospectively. Tumor size, arterial enhancement, venous washout, and apparent diffusion coefficient (ADC) values of lesions, peritumoral parenchyma, normal liver parenchyma, and spleen were recorded before and after treatment. The significance of differences between ADC values of responding and nonresponding lesions was calculated. RESULTS The study included 77 HCC lesions (mean diameter, 31.4 mm) in 20 patients. There was no significant reduction in mean tumor diameter after treatment. Reduction in tumor enhancement in the arterial phase was statistically significant (P = .01). Tumor ADC value increased from 1.10 × 10(-3) mm(2)/s to 1.27 × 10(-3) mm(2)/s after treatment (P < .01), whereas the ADC values for liver and spleen remained unchanged. ADC values from cellular parts of the tumor and necrotic areas also increased after treatment. However, pretreatment ADC values were not reliable to identify responding lesions according to the results of receiver operating characteristic analysis. CONCLUSIONS After transarterial chemoembolization, responding HCC lesions exhibited decreases in arterial enhancement and increases in ADC values in cellular and necrotic areas. Pretreatment ADC values were not predictive of response to chemoembolization.

Endovascular treatment of cranial aneurysms with the pipeline flow-diverting stent: preliminary mid-term results.

PURPOSE We aimed to present our initial experience with a new self-expanding flow diverter device designed for wide-neck aneurysm treatment, assess its safety for intracranial deployment and efficacy of occlusion at mid-term follow-up. MATERIALS AND METHODS Forty-five consecutive patients with difficult aneurysmal anatomy underwent an endovascular treatment. Fifty-five intracranial aneurysms were clipped using the Pipeline flow-diverting stent (ev3 Inc., Plymouth, Minnesota, USA) between November 2009 and December 2011. Data including antiplatelet therapy, technical issues, complications, and imaging findings were recorded during the follow-up period. RESULTS Twenty-seven aneurysms were asymptomatic, 13 were symptomatic due to mass effect, seven were recurrent, six had subarachnoid hemorrhage, and two subjects presented with ischemia. There were 45 saccular, six fusiform-dissecting, and four blister aneurysms. The six-month control angiography was available in 34 subjects with an 85.3% (29/34 patients) complete occlusion rate. The overall occlusion rate according to the last angiography was 91.9% (34/37 patients). The following three major technical complications without clinical consequences were encountered: one distal wire fracture of the stent delivery system and two insufficient stent expansion. There was one fatal nonaneurysmal cerebellar hemorrhage. The overall mortality rate was 2.2% with no permanent morbidity. CONCLUSION The Pipeline flow-diverting stent represents an important advancement in endovascular therapy for cerebral aneurysms. Standard endovascular techniques are typically not suitable for these types of aneurysms. The device targets primary parent vessel reconstruction rather than endosaccular occlusion to achieve exclusion of the aneurysm and maintain a relatively high occlusion rate at six months.

Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome: Angioplasty and Stenting with or without Manual Aspiration Thrombectomy and Catheter-Directed Thrombolysis

PURPOSE May-Thurner syndrome (MTS) is a rare clinical entity featuring venous obstruction of the left lower extremity. The aim of the present study was to report our experience with MTS and to evaluate the utility of treatment using endovascular techniques. MATERIALS AND METHODS We retrospectively analyzed data on 23 MTS patients (21 females, two males; mean age 44 ± 15 years). Eighteen patients presented with deep vein thrombosis (DVT) and five with symptoms associated with chronic venous hypertension (CVH). DVT patients were treated via thromboaspiration, catheter-directed thrombolysis, and angioplasty; followed by stent placement. CVH patients were treated with angioplasty and stent placement alone. All patients were followed-up using Doppler ultrasonography and computed tomography venography. RESULTS Complete left common iliac vein patency was achieved in 21 of the 23 patients (technical success rate: 91,3%). Complete thrombolysis was attained by 14 of the 18 DVT patients (77.7%). The mean clinical and radiological follow-up time was 15.2 ± 16.1 months. Upon follow-up, complete symptomatic regression was observed in 19 of the 23 patients (82.6%). Stent patency was complete in 19 of the 21 patients (90.4%) who received stents. Restenosis occurred in two patients. No treatment-related mortality or morbidity was observed. CONCLUSION Endovascular treatment of MTS is safe and effective and reduces symptoms in most patients, associated with high medium-term patency rates.

Continuous intra-arterial infusion of nimodipine during embolization of cerebral aneurysms associated with vasospasm.

BACKGROUND AND PURPOSE: Despite rigorous efforts, cerebral vasospasm remains an important cause of morbidity and mortality in patients who survive their initial subarachnoid hemorrhage. In cases of intracranial ruptured aneurysm associated with vasospasm, we evaluated the effectiveness of combined embolization of an aneurysm and intra-arterial infusion of nimodipine, which continued during the entire procedure. Materials and METHODS: Ten patients with ruptured aneurysms associated with vasospasm who were treated in a single session were reviewed retrospectively. After initial intra-arterial infusion of nimodipine (1–2 mg within 10–15 minutes), they underwent occlusion of the aneurysm with coils under continuous intra-arterial infusion of nimodipine at a dose of 1 mg per hour. RESULTS: Angiography showed severe proximal vasospasm in 1 patient, proximal and distal in 3 patients, and distal in 3 patients. There was also moderate proximal vasospasm in 4 patients, proximal and distal in 1 patient, and distal in 1 patient. Complete occlusion of the aneurysm was achieved in 5 patients, incomplete occlusion in 3 patients, and a small neck remnant in 2 patients. Final angiograms also demonstrated complete clearance of a proximal spasm in 4 patients, and complete clearance of proximal and distal spasms in another 4 patients. Mean initial dose of nimodipine was 1.375 mg, and mean continuous infusion dose was 1.275 mg (mean total dose, 2.65 mg). No medical complications related to extended infusion of nimodipine occurred. CONCLUSION: In this small series, extended intra-arterial infusion of nimodipine up to the end of the embolization procedure was effective and safe in patients with a ruptured aneurysm and associated vasospasm. This technique seems to increase the security of the procedure as well as force further vasorelaxation when the endovascular route is used to treat both the aneurysm and vasospasm in a single step.

Endovascular Management of Vascular Injury during Transsphenoidal Surgery.

Vascular injury is an unusual and serious complication of transsphenoidal surgery. We aimed to define the role of angiography and endovascular treatment in patients with vascular injuries occurring during transsphenoidal surgery. During the last ten-year period, we retrospectively evaluated nine patients with vascular injury after transsphenoidal surgery. Eight patients were symptomatic due to vascular injury, while one had only suspicion of vascular injury during surgery. Four patients presented with epistaxis, two with subarachnoid hemorrhage, one with exophthalmos, and one with hemiparesia. Emergency angiography revealed a pseudoaneurysm in four patients, contrast extravasation in two, vessel dissection in one, vessel wall irregularity in one, and arteriovenous fistula in one. All patients but one were treated successfully with parent artery occlusion, with one covered stent implantation, one stent-assisted coiling method, while one patient was managed conservatively. One patient died due to complications related to the primary insult without rebleeding. Vascular injuries suspected intra or postoperatively must be investigated rapidly after transsphenoidal surgery. Endovascular treatment with parent artery occlusion is feasible with acceptable morbidity and mortality rates in the treatment of vascular injuries occurring in transsphenoidal surgery.

Tailoring platelet inhibition according to multiple electrode aggregometry decreases the rate of thrombotic complications after intracranial flow-diverting stent implantation

Background and purpose Pretreatment with dual antiaggregant drugs is accepted as a standard step in intracranial stent implantation. The aim of this study was to determine whether tailored antiaggregant medication based on platelet reactivity testing with multiple electrode aggregometry (Multiplate) yields superior outcomes after intracranial flow-diverting stent (FDS) implantation compared with standard clopidogrel treatment. Methods We retrospectively analyzed the following data from 100 consecutive patients: endovascular procedure characteristics, antiaggregant medications, procedural variables, and perioperative complications after FDS implantation for intracranial aneurysm. Patients were divided into two groups: uniform treatment with clopidogrel (untailored, early phase) and tailored treatment based on the results of aggregometry (late phase). Statistical comparisons included the Fisher exact test to compare categorical variables between the standard and aggregometry groups and the Mann–Whitney U test to compare ADP test values within the aggregometry group between groups receiving tailored or untailored treatment. Results In the aggregometry group (68 patients, 71 procedures) there were 17 (25%) clopidogrel-resistant patients, according to a cut-off value of 468 area under the aggregation curve; 12 underwent FDS implantation under tailored antiaggregant medication. In the standard treatment group (32 patients, 33 procedures) there were 3 (9.1%) spontaneous thrombotic events and 1 (3.3%) technical hemorrhagic complication. In the aggregometry group there were 2 (2.8%) spontaneous hemorrhagic events and 1 (1.4%) technical ischemic complication. In the aggregometry group, thrombotic complications and morbidity were lower than in the standard (no test) group (p<0.03). Conclusions Tailoring platelet reactivity according to multiple electrode aggregometry decreases the rate of thrombotic complications after intracranial FDS implantation.

Applications of the Amplatzer Vascular Plug to various vascular lesions.

The Amplatzer® Vascular Plug (AVP) can be used to embolize medium-to-large high-flow vessels in various locations. Between 2009 and 2012, 41 AVPs (device size, 6-22 mm in diameter) were used to achieve occlusion in 31 patients (24 males, seven females) aged 9-92 years (mean age, 54.5 years). The locations and indications for embolotherapy were as follows: internal iliac artery embolization before stent-graft repair for aorto-iliac (n=6) and common iliac artery (n=3) aneurysms, subclavian artery embolization before stent-graft repair for thoracic aorta (n=3) and arcus aorta (n=1) aneurysms, brachiocephalic trunk embolization before stent-graft repair for a thoracic aorta aneurysm (n=1), embolization of aneurysms and pseudoaneurysms (n=5), embolization for carotid blow-out syndrome (n=3), closure of arteriovenous fistula (n=8), and closure of a portosystemic fistula (n=1). Of the 41 AVPs, 30 were AVP 2 and 11 were AVP 4. The mean follow-up duration was 4.7 months (range, 1-24 months). During follow-up, there was one migration, one insufficient embolization, and one recanalization. The remaining vascular lesions were successfully excluded from the circulation. The AVP, which can be used in a wide spectrum of pathologies, is easy to use and causes few complications. This essay presents our experience with the AVP.

Carotid and vertebrobasilar rete mirabile: a case report

Bilateral symmetrical absence of the cavernous segments of the internal carotid artery (ICA) and absence of proximal basilar artery with a compensating arterial network (rete mirabile) is quite rare. Although it is found in some lower mammals as a physiological network supplying the circle of Willis, it is associated with ICA hypoplasia or nonpersistence in humans. We present a case of both cavernous ICA and proximal part of basilar artery absence associated with rete formation, which was an incidental finding during cerebral angiography in a 32-year-old woman with a complaint of left maxillary sinus mass.

Endovascular Treatment of AVF after Hair Transplantation

Arteriovenous fistula (AVF) of the scalp is a very rare complication of hair transplantation. Only 9 cases have been reported in nearly half a century. The diagnosis is clinical but angiography is necessary for defining the angioarchitecture of the lesion. Due to technical developments, endovascular embolization has become the primary treatment for AVF of the scalp.

Evaluation of Platelet Distribution Width and Mean Platelet Volume in Patients With Carotid Artery Stenosis

Platelets contribute to the pathogenesis of atherosclerosis. Platelet activation has been linked with increased mean platelet volume (MPV) and platelet distribution width (PDW). We investigated the association between PDW, MPW, and the degree of carotid artery stenosis (CS). Patients (n = 229) were divided into 3 groups according to the North American Symptomatic Carotid Endarterectomy Trial criteria. Demographic and clinical features were collected retrospectively. Correlation analysis showed a positive association between PDW and the degree of CS. However, there was no significant correlation between CS and MPV. Moreover, we observed that PDW and low-density lipoprotein cholesterol were independent predictors of the degree of CS. This study showed that PDW, not MPV, is related to the degree of CS. Platelet distribution width could be a useful biomarker for CS. Whether targeting PDW will be of clinical benefit remains to be established.