Dimitrios A. Kelekis

A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting.

BackgroundPercutaneous metal stenting is an accepted palliative treatment for malignant biliary obstruction. Nevertheless, factors predicting survival are not known.MethodsSeventy-six patients with inoperable malignant biliary obstruction were treated with percutaneous placement of metallic stents. Twenty patients had non-hilar lesions. Fifty-six patients had hilar lesions classified as Bismuth type I (n = 15 patients), type II (n = 26), type III (n = 12), or type IV (n = 3 patients). Technical and clinical success rates, complications, and long-term outcome were recorded. Clinical success rates, patency, and survival rates were compared in patients treated with complete (n = 41) versus partial (n = 35) liver parenchyma drainage. Survival was calculated and analyzed for potential predictors such as the tumor type, the extent of the disease, the level of obstruction, and the post-intervention bilirubin levels.ResultsStenting was technically successful in all patients (unilateral drainage in 70 patients, bilateral drainage in 6 patients) with an overall significant reduction of the post-intervention bilirubin levels (p < 0.001), resulting in a clinical success rate of 97.3%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial liver drainage. Minor and major complications occurred in 8% and 15% of patients, respectively. Mean overall primary stent patency was 120 days, while the restenosis rate was 12%. Mean overall secondary stent patency was 242.2 days. Patency rates were similar in patients with complete versus partial liver drainage. Mean overall survival was 142.3 days. Survival was similar in the complete and partial drainage groups. The post-intervention serum bilirubin level was an independent predictor of survival (p < 0.001). A cut-off point in post-stenting bilirubin levels of 4 mg/dl dichotomized patients with good versus poor prognosis. Patient age and Bismuth IV lesions were also independent predictors of survival.ConclusionsPercutaneous metallic biliary stenting provides good palliation of malignant jaundice. Partial liver drainage achieved results as good as those after complete liver drainage. A serum bilirubin level of less than 4 mg/dl after stenting is the most important independent predictor of survival, while increasing age and Bismuth IV lesions represent dismal prognostic factors.

Endovascular Treatment of Occlusive Lesions of the Subclavian and Innominate Arteries

Technical success is defined as less than 20% residual stenosis depicted by posttreatment digital subtraction angiography (DSA), without dissection or extravasation. Hemodynamic success is defined as the absence of bilateral brachial blood pressure difference and the availability of adequate inflow artery for the scheduled bypass procedure. Clinical success is defined as the resolution of the symptoms. Patency of the treated vessel (or segment) during follow-up is better demonstrated by means of imaging such as DSA. The use of other imaging methods such as magnetic resonance angiography (MRA) or color Doppler ultrasound are limited because of the presence of the metallic stent or the deep location of the treated segment. The indirect methods recommended for the lower extremity arterial endovascular procedures, such as ankle-brachial index (ABI) measurements, are not applicable for subclavian and innominate artery interventions [40]. As a result, many published reports use clinical criteria to evaluate the patency of the treated vessel. Primary patency is defined as the uninterrupted vessel patency with no procedure performed on the treated segment. Secondary patency is defined as whenever maintenance of patency requires a secondary intervention.

Pancreatitis-Associated Splenic Artery Pseudoaneurysm: Endovascular Treatment with Self-Expandable Stent-Grafts

We present a patient with a splenic artery pseudoaneurysm (SAPA) treated with placement of self-expandable stent-grafts. The procedure was complicated by stent-graft migration, but successful management resulted in lasting exclusion of the SAPA, while the patency of the splenic artery was preserved. This is the first report of self-expandable stent-graft treatment of SAPA.

Emergency endovascular treatment of a superior mesenteric artery occlusion.

Endovascular treatment of acute mesenteric ischemia is rarely reported. We report a patient with a 1-year history of chronic mesenteric ischemia who presented with acute worsening of his symptoms and peritoneal signs. Aortography depicted an occlusion of the superior mesenteric artery, which was successfully managed with immediate percutaneous angioplasty (PTA) and stent placement. The patient’s clinical condition improved markedly and an exploratory laparotomy performed the following day confirmed the viability of the intestine. He remains symptom-free 12 months after the procedure, and color Doppler follow-up showed that the stent is patent.

Hepatic resection for hepatocellular carcinoma exceeding Milan criteria

BACKGROUND Many hepatocellular carcinomas (HCCs) are discovered at an advanced stage. The efficacy of transplantation for such tumors is doubtable. The aim of this retrospective study was to determine liver resection efficacy in patients with large HCC regarding long term and disease- free survival. METHODS Between 2002 and 2008, sixty six patients with large HCC (>5cm) underwent hepatectomy. Fifty nine patients had background cirrhosis due to hepatitis B, C or other reason and preserved liver function (Child A). Liver function was assessed by both Childs-Pugh grading and MELD score. Conventional approach of liver resection was performed in most cases. RESULTS The 5-year overall survival was 32% with a median follow up of 33 months. The three year disease-free survival was 33% in our cohort. On multivariate analysis, only tumor size and grade remained independent predictors of adverse long term outcome. Multivariate analysis identified size of the primary tumour and degree of differentiation as risk factors for recurrence. Median blood loss was 540ml and median transfusion requirements were two units of pack red blood cells. Morbidity included pleural effusion (n=18), biliary fistula (n=4), peri-hepatic abscess (n=4), hyperbilirubinemia (n=3), pneumonia (n=5) and wound infection (n=6). No peri-operative mortality was reported in our study. CONCLUSION Partial hepatectomy is safe in selective patients with large HCC. Surgical resection if feasible is suggested in patients with large HCC because it prolongs both overall and disease-free survival with low morbidity.

Common Femoral Artery Anastomotic Pseudoaneurysm: Endovascular Treatment with Hemobahn Stent-Grafts

JVIR 2000; 11:1179–1183 STENT-GRAFTS are gaining widespread acceptance in the endovascular treatment of aneurysms, pseudoaneurysms, and arteriovenous fistulas because of the less invasive nature of their use compared to standard surgical procedures (1). Fully supported stent-grafts are used in the treatment of thoracic aortic aneurysms (1), abdominal aortic aneurysms (2), iliac artery aneurysms (3–6), superficial femoral artery (SFA) and popliteal artery pseudoaneurysms (7–10), and subclavian artery aneurysms and fistulas (11). Vascular lesions near mobile skeletal joints (ie, hip joint), although potentially treatable with fully supported stents or stent-grafts, are still managed with surgery (12) because of the perceived risk of stent failure or vascular injury caused by motion. To our knowledge, there have been no reports of a fully supported stent-graft placement across the hip joint for the treatment of aneurysmal lesions in humans. We describe our experience of endovascular management of a patient presenting with a common femoral artery (CFA) anastomotic pseudoaneurysm, treated with placement of fully supported stentgrafts. This patient also had a common iliac artery anastomotic pseudoaneurysm that was likewise treated with placement of fully supported stent-grafts.

Ruptured adrenal artery aneurysm: a case report

Abstract. A case of ruptured adrenal artery aneurysm is presented. The ultrasound, computed tomography and selective renal angiography findings are described in detail. Aneurysms of adrenal arteries are particularly rare. Early diagnosis is important because of their tendency towards rupture and subsequent high mortality rate.

Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria

BACKGROUND Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome. METHODS Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant. RESULTS In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P= 0.04). The recurrence rate was higher in group B (P= 0.002). CONCLUSIONS Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score.

Congenital Subclavian Artery–to–Subclavian Vein Fistula in an Adult: Treatment with Transcatheter Embolization

We report the combined use of an occlusion balloon catheter and a microcatheter for transcatheter arterial embolization (TAE) of hepatocellular carcinoma (HCC) fed by the unselectable right inferior phrenic artery (IPA). In one case, HCC was fed by the reconstructed right IPA via a small branch arising from the proximate portion of the celiac artery. In another, the tumor was fed by the right IPA that had been previously embolized with coils. TAE was successfully performed through a microcatheter placed in the celiac artery immediately proximal to the occluding balloon catheter of the celiac trunk and coil embolization of the left gastric artery.

Internal Iliac Artery Aneurysm Embolization with Fibrin Sealant: A Simple and Effective Solution

Endovascular treatment of internal iliac artery (IIA) aneurysms is an attractive alternative to surgical management, because the former is associated with less morbidity and mortality. Embolization with coils or exclusion of the IIA orifice with stent-grafts are the preferred techniques. Although uncommon, technical failures occur with reported aneurysm rupture. Two patients with IIA aneurysms are reported here, where we describe successful occlusion of their IIA aneurysms with the use of fibrin sealant, after initial failure of coil embolization.