Daisuke Yasui

Interventional treatment for unresectable hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Endovascular embolization strategy for renal arteriovenous malformations.

Background Renal arteriovenous malformations (AVMs) are rare vascular malformations that cause hematuria. Treatment for renal AVMs has evolved from open nephrectomy to transcatheter arterial embolization (TAE). Purpose To retrospectively evaluate efficacy and adverse events of TAE for renal AVMs. Material and Methods We examined 12 patients (three men, nine women; mean age, 56 years) with renal AVM with gross hematuria, who underwent 14 sessions of treatment, using various embolization materials (liquid embolization agents, gelatin sponge, and coils). Among the 12 patients, 10 had cirsoid AVMs, eight of which were high-flow lesions. The remaining two patients had aneurismal AVMs. We assessed technical and clinical success, and also complications. All patients were followed for 7–92 months (mean, 48 months). Results Technical success was obtained in all patients. Primary clinical success was obtained in all patients; however, recurrence was observed in two patients who were treated with coils alone. A second session of TAE led to the sustained relief of symptoms. Clinical success rate was significant better (P = 0.045) when coils combined with other agents or liquid agents were used, than when only coils were used. No major complications occurred in any of patients; post-embolization syndrome and deterioration of renal function were not observed. Conclusion TAE treatment was safe, effective, and provided a good outcome, except when only coils were used as the embolization agent.

Transcatheter Arterial Chemoembolization Based on Hepatic Hemodynamics for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related deaths in the world. The Barcelona Clinic Liver Cancer (BCLC) classification has recently emerged as the standard classification system for clinical management of patients with HCC. According to the BCLC staging system, curative therapies (resection, transplantation, and percutaneous ablation) can improve survival in HCC patients diagnosed at an early stage and offer potential long-term curative effects. Patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE), and those diagnosed at an advanced stage receive sorafenib, a multikinase inhibitor, or conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. TACE is often recommended for advanced-stage HCC patients all over the world because these patients desire therapy that is more effective than systemic chemotherapy or conservative treatment. This paper aims to summarize both the published data and important ongoing studies for TACE and to discuss technical improvements in TACE for advanced-stage HCC.

Endovascular recanalization techniques for popliteal arterial occlusive injury with limb-threatening ischemia secondary to trauma

To date, no ideal endovascular strategy has been established for traumatic arterial occlusion. Here, we report the outcomes of a combination of endovascular recanalization techniques applied in two patients with high risk of leg amputation. A 33-year-old man with popliteal artery occlusion due to blunt trauma was treated by balloon angioplasty with long inflation time and aspiration thrombectomy. A 74-year-old woman with popliteal artery occlusion after total knee replacement was treated by aspiration thrombectomy and stent placement. In both cases, we achieved satisfactory recanalization, and peripheral ischemia was absent even 1 year later.

Comparison of the antitumor efficacy of transcatheter arterial chemoembolization with a miriplatin-iodized oil suspension and a cisplatin-iodized oil suspension for hepatocellular carcinoma.

To retrospectively compare the short‐term antitumor efficacy and safety of transcatheter arterial chemoembolization (TACE) with a cisplatin‐iodized oil suspension (C‐IS) and a miriplatin‐iodized oil suspension (M‐IS) for hepatocellular carcinoma (HCC).

Anatomical relationship between the common carotid artery and the internal jugular vein during head rotation

This study investigated the anatomical relationship between the common carotid artery and internal jugular vein during head rotation for the effective performance of percutaneous transjugular procedures. The subjects included 30 volunteers who had never undergone internal jugular vein cannulation. In the supine position, two-dimensional ultrasonographic images of the right internal jugular vein and common carotid artery were obtained, 2 and 4 cm above the clavicle, along the lateral border of the sternal head of the sternocleidomastoid muscle. Ultrasonographic images were examined for head rotation at 0°, 15°, 30°, 45°, 60°, and 75° from the midline to the left. The percentage of overlap of the common carotid artery by the internal jugular vein and the flattening of the internal jugular vein at each head rotation position were measured and evaluated. The overlap of the common carotid artery by the internal jugular vein significantly increased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01), compared with that observed in the neutral position. The flattening of the internal jugular vein significantly decreased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01). Head rotation should be kept to <45° at 2 cm above the clavicle and <30° at 4 cm above the clavicle to decrease the risk of accidental puncture of the common carotid artery during internal jugular vein puncture. Moreover, flattening of the internal jugular vein gradually decreases during head rotation to the side.

Management of Gastric Varices Unsuccessfully Treated by Balloon-Occluded Retrograde Transvenous Obliteration: Long-Term Follow-Up and Outcomes

Our aim was to evaluate the long-term efficacy and safety of percutaneous transhepatic obliteration (PTO) alone and combined with balloon-occluded retrograde transvenous obliteration (BRTO) for gastroesophageal varices refractory to BRTO alone. Between July 1999 and December 2010, 13 patients with gastroesophageal varices refractory to BRTO were treated with PTO (n = 6) or a combination of PTO and BRTO (n = 7). We retrospectively investigated the rates of survival, recurrence, or worsening of the varices; hepatic function before and after the procedure; and complications. The procedure achieved complete obliteration or significant reduction of the varices in all 13 patients without major complications. During follow-up, the varices had recurred in 2 patients, of which one had hepatocellular carcinoma, and the other died suddenly from variceal rebleeding 7 years after PTO. The remaining 11 patients did not experience worsening of the varices and showed significant improvements in the serum ammonia levels and prothrombin time. The mean follow-up period was 90 months, and the cumulative survival rate at 1, 3, and 5 years was 92.9%, 85.7%, and 85.7%, respectively. Both PTO and combined PTO and BRTO seem as safe and effective procedures for the treatment of gastroesophageal varices refractory to BRTO alone.

Amplatzer Vascular Plug Anchoring Technique to Stabilize the Delivery System for Microcoil Embolization

PurposeTo evaluate the feasibility of a novel embolization technique, the Amplatzer vascular plug (AVP) anchoring technique, to stabilize the delivery system for microcoil embolization.Materials and methodsThree patients were enrolled in this study, including two cases of internal iliac artery aneurysms and one case of internal iliac arterial occlusion prior to endovascular aortic repair. An AVP was used in each case for embolization of one target artery, and the AVP was left in place. The AVP detachment wire was then used as an anchor to stabilize the delivery system for microcoil embolization to embolize the second target artery adjacent to the first target artery. The microcatheter for the microcoils was inserted parallel to the AVP detachment wire in the guiding sheath or catheter used for the AVP.ResultsThe AVP anchoring technique was achieved and the microcatheter was easily advanced to the second target artery in all three cases.ConclusionThe AVP anchoring technique was found to be feasible to advance the microcatheter into the neighboring artery of an AVP-embolized artery.

Minimizing Systemic Leakage of Cisplatin during Percutaneous Isolated Pancreas Perfusion Chemotherapy: A Pilot Study

PURPOSE To evaluate the feasibility of percutaneous isolated pancreas perfusion (PIPP) by using a pig model. MATERIALS AND METHODS All experiments were approved by the institutional Animal Experiment Ethics Committee. Fifteen pigs were assigned to five groups, and PIPP was performed. Angiographic and dye injection studies were performed to confirm the patency of the PIPP system (group 1). Blood that contained cisplatin (1.5 mg per kilogram of body weight) in an extracorporeal circuit was circulated through the pancreas at three infusion rates (40, 60, and 80 mL/min) to determine the optimal infusion rate in terms of safety and pharmacologic effectiveness (groups 2, 3, and 4, respectively). Chronological laboratory data and histologic findings were assessed in group 5, which received the optimal infusion rate. Maximum platinum concentration (Cmax) and area under the platinum concentration-time curve were compared by using the Kruskal-Wallis and Mann-Whitney U tests. RESULTS Angiography and dye injection confirmed the patency of the PIPP system. Histopathologic examinations showed no abnormalities in the pancreas or other organs at a 40 mL/min infusion rate of cisplatin. However, edematous changes in the pancreas were observed at higher infusion rates. The pharmacologic effectiveness did not differ significantly among groups; therefore, the optimal infusion rate of 40 mL/min was selected. The median pancreatic-to-systemic exposure ratios were 71.8 for Cmax and 54.8 for the area under the curve. All laboratory data remained normal or returned to pretreatment levels within 1 week. CONCLUSION PIPP at a 40 mL/min infusion rate appears to be safe and feasible for perfusion of the pancreas.

Improved efficacy of transcatheter arterial chemoembolization using warmed miriplatin for hepatocellular carcinoma.

The aim of this study was to evaluate the efficacy and safety of transcatheter arterial chemoembolization (TACE) using warmed and nonwarmed miriplatin for hepatocellular carcinoma. Eighty patients (117 nodules), treated between January 2010 and June 2013, were evaluated. Thirty-two and 85 nodules were treated with nonwarmed and warmed miriplatin, respectively. The efficacy of TACE was evaluated on a per nodule basis according to treatment effect (TE). Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. TE grades were significantly improved in the warmed group compared to the nonwarmed group (nonwarmed: TE 4, 12.5%; TE 3, 0%; TE 2, 15.6%; TE 1, 71.9%; warmed: TE 4, 34.1%; TE 3, 5.9%; TE 2, 9.4%; TE 1, 50.6%; P = 0.017) . Multivariate analysis revealed significant impact of warming miriplatin on objective response rate (odds ratio, 12.35; 95% confidence interval, 2.90–90.0; P = 0.0028). CTCAE grades of elevated aspartate and alanine transaminase after TACE were significantly higher in the warmed group (P = 0.0083 and 0.0068, resp.); however, all adverse events were only transient. The use of warmed miriplatin in TACE significantly improved TE without causing serious complications.