David Valenti

Günther Tulip Retrievable Vena Cava Filter: Results from the Registry of the Canadian Interventional Radiology Association

PURPOSE To report data collected by the Canadian Registry of the Günther Tulip Retrievable Filter (GTF). MATERIALS AND METHODS Between February 1998 and December 2000, 90 patients at eight hospitals underwent implantation of 91 GTFs. There were 45 male patients and 45 female patients, age 17-88 years, with a mean age of 49 years. Indications for filter placement were pulmonary embolism (PE) or deep vein thrombosis (DVT) with a contraindication to anticoagulation in 83 patients, prophylaxis after massive PE in one, prophylaxis for proximal free-floating thrombus in one, and prophylaxis with no DVT or PE in six patients (major trauma, n = 4; high preoperative risk, n = 2). GTF retrieval was attempted in selected patients from a right internal jugular vein approach. RESULTS One GTF was inadvertently placed in the right iliac vein and could not be retrieved. There were no other major placement complications. GTF retrieval was attempted in 52 patients (53 GTFs); 52 GTFs were successfully retrieved from 51 patients. Implantation times were 2-25 days (mean, 9 d). Of these 51 patients, 37 underwent follow-up for 5-420 days (mean, 103 d) after filter retrieval. Four patients (8% of retrieved GTFs) required reinsertion of a permanent filter 17-167 days (mean, 78 d) after GTF retrieval as a result of bleeding from anticoagulation (n = 2) or because the patient required further surgery (n = 2). One other patient had recurrent DVT 230 days after retrieval; no PE or other complication was documented in the retrieval group. GTFs were not retrieved from 39 patients for various reasons. Of these 39 patients, 25 underwent follow-up 7-420 days (mean, 85 d) after filter placement. Two patients developed filter occlusion (5%); no other complications were documented. CONCLUSION The GTF has a broad range of utility: it can be used as a permanent filter or retrieved after implantation periods of 15 days and possibly longer. However, indications for retrieval require further study, as does the maximum implantation time.

Research Reporting Standards for Radioembolization of Hepatic Malignancies

Primary Liver Tumors Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver; its incidence is increasing worldwide. It ranks as the sixth most common tumor and third most common cause of cancer-related mortality (1,2). Primary liver tumors include HCC and intrahepatic cholangiocarcinoma. Surgical resection is preferred over transplantation and is considered potentially curative in patients with resectable HCC and normal liver function (3). Transplantation is considered the gold standard for patients with unresectable HCC and whose disease is within the Milan criteria (4). Resection and transplantation have limited roles, given advanced disease (chronic liver disease and/or tumor extent) at presentation and limited organ availability (5–7). Chemoembolization and radiofrequency ablation represent standard therapies in treating patients and serve as a bridge to transplantation in selected patients (8,9). Radioembolization has an emerging role in “bridging” patients within criteria by delaying tumor progression. It has also been shown to downstage disease beyond the Milan, to within, transplant criteria (10–12). A recent study has demonstrated that radioembolization leads to longer time-to-progression and better toxicity profile when compared with chemoembolization (13). Patients with macrovascular tumor involvement have also exhibited evidence of clinical benefit after radioembolization (14).

Vascular Calcifications in Homozygote Familial Hypercholesterolemia

Background—Patients with homozygous familial hypercholesterolemia (hmzFH) attributable to LDL receptor gene mutations have shown a remarkable increase in survival over the last 20 years. Early onset coronary heart disease (CHD) and calcific aortic valve stenosis are the major complications of this disorder. We now report extensive premature calcification of the aorta in patients with hmzFH. Methods and Results—We examined 25 hmzFH patients from Canada; mean age was 32 years (range 5 to 54), and mean baseline cholesterol before treatment was 19±5 mmol/L (737±206 mg/dL). Aortic calcification was quantified using computed tomography (CT). An elevated mean calcium score was found in patients by age 20 and correlated with age (r2=0.53, P=0.001). One quarter (24%) of patients underwent aortic valve surgery. Conclusions—We document premature severe aortic calcifications in all adult hmzFH patients studied. These presented considerable surgical management challenges. Strategies to identify and monitor aortic calcification in hmzFH by noninvasive techniques are required, as are clinical trials to determine whether additional or more intensive therapies will prevent the progression of such calcifications. Whether vascular calcifications in hmzFH subjects are related to sustained increases in LDL-C levels or to other mechanisms, such as abnormal osteoblast activity, remains to be determined.

Ovarian Function after Uterine Artery Embolization and Hysterectomy

STUDY OBJECTIVE To evaluate the effect of uterine artery embolization (UAE) and hysterectomy on ovarian function. DESIGN Prospective case control study (Canadian Task Force classification II-2). SETTING University teaching hospital. PATIENTS Eighty-four healthy premenopausal women with symptomatic uterine myoma(s) undergoing UAE or hysterectomy. INTERVENTION Patients had blood drawn to measure follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels and underwent transvaginal ultrasound to measure volume of the myoma(s) and uterus on cycle day 3 before the procedures. These measurements were repeated 3 and 6 months after treatment. MEASUREMENTS AND MAIN RESULTS The main outcome was the differences in serum FSH, LH, E2, and ultrasound findings before and after UAE or hysterectomy. Of the 68 patients who underwent UAE and 16 who underwent hysterectomy, 48 and 13 respectively, completed 6-month follow-up. The mean age of the patients in the UAE group was 44.9 +/- 3.8 years and 43.7 +/- 5.6 years in the hysterectomy group. There was no significant difference in serum FSH before (8.9 +/- 0.7 IU/L) and 6 months after UAE (9.9 +/- 1.0 lU/L), and between the baseline (10.4 +/- 1.8 lU/L) and 6 months posthysterectomy (7.8 +/- 1.8 lU/L). The uterine volume 6 months after UAE (361 +/- 50 mL) was significantly smaller than before UAE(538 +/- 38mL; p =.005, 95% CI 44-241). Compared with baseline (154 +/- 20 mL), the dominant myoma volume was smaller at 6 months after UAE (97 +/- 16 mL; p <.05, 95% CI 1.57-62). CONCLUSION Uterine artery embolization is associated with a significant reduction in myoma and uterine volume. Ovarian function at 6 months, as indicated by day 3 FSH levels, is not affected by UAE or hysterectomy.

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

OBJECTIVES Portal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth. METHODS Computed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE. RESULTS A total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P= 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P= 0.825). CONCLUSIONS Adequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.

Endoleakage after endovascular treatment of abdominal aortic aneurysms: diagnosis, significance and treatment

Endoleak, also called leakage, leak and Perigraft leak, is a major complication and its persistence represents a failure of endovascular aortic aneurysm repair. Its detection and treatment is therefore of primary importance, since endoleak can be associated with pressurization (increase in pressure) of the sac, resulting in expansion and rupture of the aneurysm. The aim of this paper is to discuss the definition, significance, diagnosis and different options to treat endoleak.

Predictors of response to radio‐embolization (TheraSphere®) treatment of neuroendocrine liver metastasis

BACKGROUND Neuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases. METHODS From January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization). RESULTS In all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance. CONCLUSION Radio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

Aortic calcifications in familial hypercholesterolemia: Potential role of the low-density lipoprotein receptor gene

BACKGROUND We have previously reported premature, extensive aortic calcifications in patients with homozygous familial hypercholesterolemia (hmzFH) due to mutations in the low-density lipoprotein receptor gene (LDL-R). The objective of this study was to measure the degree of aortic calcification in heterozygous FH (htzFH) compared to both hmzFH and controls. We hypothesized that the LDL-R gene may contribute to aortic calcifications in a gene-dosage effect. METHOD Patients with htzFH due to the French Canadian mutation (Delta15 kb del. null allele) were selected. All patients underwent computed tomographic scan to measure vascular calcification. We used 22 hmzFH patients from our previous study and patients undergoing computed tomographic virtual colonoscopy as controls. RESULTS Mean age for htzFH was 50 +/- 15 years; initial cholesterol level before treatment was 10.45 +/- 1.73 mmol/L. Major cardiovascular events occurred in 9 of 17 patients. A strong correlation between age and calcium score was found (r = 0.72, P = .0016). There was a strong correlation between the cholesterol-year score (an index of lifelong cholesterol burden) and the aortic calcium score (r = 0.62, P = .0105). Aortic calcifications in htzFH subjects occurred later than in hmzFH patients, but much earlier than in controls, suggesting a gene-dosage effect of LDL-R mutations and aortic calcium deposition. CONCLUSION Aortic calcification was observed in patients with htzFH but presented at a later time and were less extensive than in hmzFH (34 vs 14 years, respectively). Because aortic calcifications may be partly independent of serum cholesterol levels in patients with familial hypercholesterolemia, implications for screening and the timing of treatment initiation may need reassessment.

Intraabdominal adhesions after uterine artery embolization

OBJECTIVE The objective of the study was to evaluate intraabdominal adhesions after uterine artery embolization (UAE). STUDY DESIGN This was a case-control study of patients who underwent hysterectomy after UAE (UAE group) in the years 2000-2006. The control group consisted of patients who underwent hysterectomy for uterine myoma in the same week. RESULTS We encountered 30 patients in the UAE group and 72 in the control group. The age of patients in the UAE group was 44.9 +/- 0.8 years and 44.6 +/- 0.6 years in the control group. In the UAE group, the diameter of the dominant myoma in patients with adhesions (11.3 +/- 1.9 cm) was larger than in those without adhesions (5.6 +/- 0.6 cm; P = .003; confidence interval, 1.9-8.5). The prevalence of adhesion in the UAE group (20%) was higher than in the control group (1.4%; P = .002; odds ratio, 17.2). CONCLUSION UAE is associated with intraabdominal adhesion formation. Large myoma predisposes to adhesion formation.

Higher Rate of Partial Devascularization and Clinical Failure After Uterine Artery Embolization for Fibroids with Spherical Polyvinyl Alcohol

Jafar Golzarian, Elvira Lang, David Hovsepian, Thomas Kroncke, Leo Lampmann, Paul Lohle, Jean-Pierre Pelage, Richard Shlansky-Goldberg, David Valenti, Dierk Vorwerk, James Spies Department of Radiology, 200 Hawkins Drive, 3957 JPP, University of Iowa, Iowa City, Iowa 52242, USA Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA Mallinckrodt Institute, St. Louis, MO 63110, USA Department of Radiology, University Clinic Charit/, Berlin 10117, Germany Department of Radiology, St. Elisabeth Hospital, AN Tilburg 5032, The Netherlands Department of Radiology, Hopital Ambroise Pare, Boulogne 92104 cedex, France University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA Royal Victoria Hospital, McGill University, Montreal, H3A 1A1 Quebec, Canada Department of Diagnosis and Imaging, Klinikum Ingolstadt, Ingolstadt 85049, Germany Georgetown University Medical Center, Washington, DC 20007, USA